Release Forms

U-M Head and Neck Cancer Program.

Out of respect for our patients’ privacy and to assure compliance with federal and state privacy laws, we may only share details about a patient’s case when that patient (or his or her legally authorized representative) signs the Release of Information Form available below.

Staff Instructions for Patient Release Forms

  1. All patients must complete a Patient Release form any time information about them, their condition or their experience at UMHS will be released publicly. “Information” includes photos and video/audio recordings in which they will be identifiable; interviews by anyone from UMHS about them; or even facilitating an interview with a reporter simply by passing along contact information.
  2. Release forms are not required for employees but they should be made aware of any filming/photographing and offered the option to decline. Release forms for family members of patients or UMHS volunteers are recommended, but not required.
  3. Before proceeding, tell the patient why you are interviewing, photographing or videotaping him or her. Be sure to explicitly state:
    1. What you plan to disclose. If you plan to disclose information about certain sensitive health conditions, including mental health and HIV/AIDS, make sure the patient understands this.
    2. Why you are asking the patient to participate;
    3. Where the materials may appear; and whether a third party, such as a news organization, is involved.
  4. If a patient indicates they want to check “no” to any box on the release form, seriously consider whether this patient is the right participant. Work to see if the patient’s concerns can be resolved by noting exceptions or restrictions on the lines provided. (For instance: “I do not wish to do any other interviews besides Channel 7.”)
  5. Make sure the patient has signed the form and filled in all fields. If the patient does not know his or her registration number, look it up in CareWeb or ask someone to do this for you.
  6. Note the new boxes below the line for “legally authorized representative.” If the patient is not signing for himself/herself, make sure one of the boxes indicating the representative’s relationship to the patient is checked.
  7. In the white space at the bottom of the form, write a note about the original occasion of use for this form. For example, “Fox 2 liver transplant story” or “Colleagues in Care, Spring 2014 issue.”
  8. Give the form to PRMC for proper routing to the patient’s medical record and PRMC files.