HIPAA Authorization & Model Release Form

The University of Colorado Anschutz Medical Campus must protect the privacy of patients and individuals disclosing health information. When capturing images or obtaining other personal health information from individuals, we are required under the Health Insurance Portability and Accountability Act (HIPAA) to obtain their permission to use the information or images by completing the HIPAA Authorization form.

As a medical campus, CU Anschutz also requires model release forms to be obtained from people who are photographed or videotaped. These forms are required in order to grant an entity permission to use the subject's image for educational, promotional, advertising or other purposes. For public events, releases generally are not required. However, it is strongly encouraged that model releases are signed by all subjects if at all possible.

Please find below the CU Anschutz HIPAA form with the option to use as a model release only. The form is available for digital signature and to download. 

• Online Form
• PDF Form (available in English and Spanish)

Do not alter this form. If you require changes to it, please contact the CU Anschutz Office of Communications at communications@cuanschutz.edu.