№ files_lp_3_process_7_054935
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Official state consent form authorizing photography or recording of a client or patient within a Wisconsin health services facility and defining conditions, limitations, and rights related to the use of resulting materials.
Form Number: F-22538
Revision Date: 11/2021
State: Wisconsin
Governing Law: Wisconsin Statutes § 51.61 (1) (o)
Administrative Code: Wis. Admin. Code § DHS 94.18
Issuing Authority: Department of Health Services, Division of Care and Treatment Services
Document Type: Consent Form
Subject: Authorization for photography, video, or audio recording and use of resulting materials
Applicable To: Clients or Patients of a Facility or Institution
Related Parties: Parent of Minor Child or Guardian
Scope of Consent: Photograph, Video, Audio Recording
Rights Included: Right to review materials prior to release; right to revoke consent in writing; right to specify limitations
Compensation Clause: No compensation for use of photographs or recordings
Impact on Benefits: Consent decision does not affect eligibility for department programs, benefits, or services
Price: 8 / 10 USD
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