La Clinica sometimes uses images, names, and information about patients or others as it tells its story in the community. Complete the form below to give La Clinica permission to use your image, name, and information publicly.
- If you are a patient, doing this won’t change the care you get at La Clinica. Signing means that any health information you share as part of an interview, photo, or recording is no longer covered by federal privacy laws and may be shared publicly by La Clinica.
- You may take back this authorization at any time in writing. Information released between the date on this form and the date you take back authorization may still be in public use.
- If you have questions, please ask a La Clinica employee for answers before signing the form.
Thank you.
Release Form
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