Free Consent to Film or Record - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care Division of Mental Health and Substance Abuse Services F-22538 (Rev. 07/2008)

STATE OF WISCONSIN ss51.61(1)(o) HFS 94.18

CONSENT TO FILM OR RECORD
Name ­ Client / Patient (Last, First MI) ID Number Name ­ Institution

By my signature below, I authorize the filming / recording as listed; and I understand that I may view the photograph or film or hear recording prior to any release. This consent may be revoked at any time by giving written notification to the institution director.
Type of Filming / Recording Photograph Video Tape Audio Tape Name ­ Individual / Group Doing the Filming / Recording Purpose / Reason for Filming / Recording: Date ­ Consent Expires CD

Resulting Materials Can Be Used By:

I further understand that I may specify periods during which or situation in which client / patient may not be filmed or recorded. I understand that neither last names nor other identifying information will be used or made available.
Filming / Recording Limitation ­ Times / Situations:

SIGNATURE ­ Client / Patient ­ If Presumed Competent

Date--Signed

SIGNATURE ­ Parent for Child (Minor) or Guardian

Relationship

Date--Signed

Distribution: Original--Patient Record