Operating Policy and Procedure
HSC OP: 52.15, Consent and Release to Use Likeness or Information
PURPOSE: The purpose of this Health Sciences Center Operating Policy and Procedure (HSC OP) is to establish a standard in obtaining faculty, staff, student, or patient consent and release for TTUHSC to use likenesses and/or information.
REVIEW: This HSC OP will be reviewed on September 1 of each even-numbered year by the Associate Provost for Student Affairs, the Assoc. Vice President for Human Resources, the Institutional Privacy Officer, Academic Affairs and Curriculum Committee, Academics Council, and the Chief Compliance Officer with recommendations for revisions forwarded to the President by November 1.
POLICY/PROCEDURE:
1. General. This policy applies to all TTUHSC Schools, educational and other activities, and areas owned, operated, and/or provided by TTUHSC. It does not apply to uses of likeness(es) or information for patient treatment or payment purposes (as defined under HIPAA).
2. Definitions.
a. Consent – means a written document signed by a faculty, staff, student, or patient (or by an authorized legal representative) agreeing to allow likeness(es) and/or information to be taken and/or used as set forth in Attachment A, “Consent and Release to Use Likeness”. Signed Consent forms shall be maintained by the department that requested the consent. Examples may include but are not limited to Human Resources, Student Affairs, Communications and Marketing, Department/Unit, School, Medical Records, or Classroom Support.
b. Likeness – refers to any representation or depiction, including, but not limited to, photographs, video recordings, audio recordings, live streaming, quotes or excerpts of written or verbally expressed words, artwork or photographs of artwork, name, alias, biographical information, and digital or other likenesses of any kind or nature.
3. Consent Process. As required under this Policy, before taking likenesses of faculty, staff, students, or patients, for purposes other than patient treatment or payment, consent shall be obtained from the individual (or authorized legal representative), using Attachment A. Individuals under the age of 18 years and adults who are unable to make an informed decision or make their decision known, require permission to be granted by their parent, legal guardian, or authorized legal representative using Attachment A. This Consent only allows TTUHSC to take and/or use likenesses or information for the purposes approved on the Consent form.
a. Obtaining Consent. A TTUHSC employee, or appropriately delegated person, is responsible for discussing the Consent with the individual (or authorized legal representative) to include the:
• purpose of obtaining likenesses or information, and
• proposed use(s) of the likenesses or information (examples include: commercial, marketing, educational, or promotional purposes).
b. Revocation of Consent: An individual (or authorized legal representative) may revoke Consent as set forth in the form. Revocation or withdrawal can happen at any time but must be in writing and sent to the department that obtained the original consent or to the TTUHSC Institutional Privacy Officer if the department is unknown. Any revocation or withdrawal of consent does not affect any information used or disclosed prior to receipt of written notice of revocation or withdrawal. No further use or disclosure shall be made of the likenesses and/or information after a written revocation is received from the individual (or authorized legal representative).
c. Program-Specific Consent: Students, employees, and participants in TTUHSC programs may be asked to sign a general consent upon admission, hiring, or program enrollment. This consent typically covers the use of their likeness for routine educational, promotional, and institutional purposes related to their role at TTUHSC.
d. Event-Specific Consent: For special events or activities that fall outside the scope of routine educational experiences—such as promotional campaigns, public events, educational events not hosted by the individual’s program, or projects involving external partners—individuals may be asked to provide additional consent. This ensures clear authorization for use in contexts not covered by the initial program-specific consent.
4. Implied Consent. TTUHSC reserves the right to capture and use photographs, video recordings, and other media at public events, large institutional gatherings, and community activities. These may include, but are not limited to commencement, white coat ceremonies, large lectures, open houses, conferences, award ceremonies, celebrations, student organization events, donor events, etc.). Attendance at such events implies consent for participants to appear in Media used for educational, promotional, and informational purposes that support TTUHSC’s mission.
To respect individual privacy, TTUHSC will provide notification through signage at event entrances and, when feasible, audio announcements during the event to inform attendees of the presence of photographers, videographers, or audio recorders. Individuals who prefer not to be photographed or recorded should notify the event staff or the designated photographer. By choosing to attend the event, individuals acknowledge this policy and waive the need for further consent.
5. Consent and Release to Use Likeness of Patient
a. When a patient’s likeness will be taken for purposes other than patient treatment or payment, in addition to obtaining the consent from the patient using the Attachment A, TTUHSC needs to obtain the patient’s HIPAA authorization to use their likeness or information. The HIPAA form “HIPAA Authorization for Public Disclosures of PHI – Photographs, Videotaping, and Interviews” should be used for this purpose.
b. Documentation of Abuse and Neglect of Patient(s). Reportable cases of actual or suspected abuse and neglect do not require written consent from a patient (or authorized legal representative) before obtaining likenesses of and/or information about the patient for required reporting purposes. The likenesses and/or information must be treated as sensitive in nature and secured as stated below and may be submitted to an investigating agency pursuant to an appropriate authorization or court order.
6. Security and Storage. All likenesses or information shall be stored in a secure manner that protects the individual’s privacy in accordance with federal and state laws. Respective areas will be responsible for security and storage of likenesses or information.
a. Likenesses and/or information of a sensitive nature shall be stored in a secure location within the medical record or elsewhere such as secure locations including, but not limited to, a secured envelope, locked file, or restricted access file within an electronic medical record or other electronic file within TTUHSC network. Likenesses and/or information of a sensitive nature shall not be stored on a non-TTUHSC owned or controlled device or network, i.e., shall not be stored on personally owned computers, laptops, external hard drives, flash drives, etc., or cloud-based storage unless approved by TTUHSC IT Security.
7. Equipment Used to Obtain TTUHSC Likenesses or Information. Only equipment owned, leased, or controlled by TTUHSC or its affiliated schools or hospitals shall be used to obtain likenesses and/or information pursuant to this policy. TTUHSC employees, representatives, or agents, including Business Associates, shall not use personal recording devices including, but not limited to, cell phones, cameras, flash drives, video recorders, etc. to take or store likenesses and/or information for or on behalf of TTUHSC.
8. Responsibility to Report. TTUHSC employees and TTUHSC affiliates have a duty to report known or suspected violations of this policy. See TTUHSC OP 52.04 Report and TTUHSC Internal Investigations of Alleged Violations; Non-Retaliation.
9. Right to Change Policy. TTUHSC reserves the right to interpret, change, modify, amend, or rescind this policy in whole, or in part, at any time without the consent of employees.