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Sensory India |
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Authorization for Assessment Using the Sensory Integration and Praxis Tests (SIPT)
Enter subhead content here Division of Occupational Science and Occupational Therapy Authorization
for Assessment Using the Sensory Integration and Praxis Tests (SIPT) I, __________________________________,
the parent or legal guardian of __________________________________, consent to and authorize testing, that will possibly include
videotaping, or recording by other means, of the above named child for demonstration purposes during a USC/WPS sponsored course
about the use of Sensory Integration theory, assessment and intervention in professional therapeutic practice. This demonstration will be observed by therapists attending the course. Said testing is solely for educational
purposes and recordings will not be sold commercially without my express consent. I understand my child
will not be identified and that neither my child nor I will receive remuneration of any kind from WPS or USC for our participation
in the testing.
___________________________
Signature of Parent/Guardian ________________________ ___________________________ Therapist Signature
Printed Name of Parent/Guardian ________________________ ___________________________ Printed Name of Therapist Signature
of Child ________________________ ___________________________ Therapist Address
Printed Name of Child ________________________ ___________________________ City, State, Zip
Address ________________________ ___________________________ Therapist Phone
City, State, Zip ________________________ ___________________________ Date
Phone Individual Rights I may refuse to sign this Authorization. Completion of this document authorizes the disclosure and/or use of individually identifiable
health information, consistent with AUTHORIZATION to VIDEOTAPE
I, ____________________________________, the parent or legal
guardian of ____________________________________, consent to and authorize videotaping, or recording by any other means, of
the above named child. Said recordings are to be used solely for educational
purposes including use in lectures and professional journals and textbooks and will not be sold commercially without my express
consent. The rights granted USC/WPS herein are perpetual and worldwide.
I understand that while my child will not be identified, the videotape will reveal my child’s picture or other
details that may disclose my child’s identity. I understand that neither my child nor I will receive remuneration of
any kind for our participation in the recordings. By signing this authorization,
I waive any right to compensation for such uses, and you and your successors also release and hold harmless USC/WPS, your
attending health care provider and Facility from and against any claim for any injury in connection with the use or display
of your image, voice, likeness or any other identifying characteristics in the presentation of your videotape, and any compensation
resulting from the activities authorized by you in this authorization.
I confirm that I have the right to enter into this agreement, that I am not restricted by any commitments to third
parties, that USC/WPS and other agents have no financial commitment or obligation to me as a result of this agreement, and
that I have had opportunities to ask questions about the use of my health information for educational and instructional purposes.
I have read the foregoing agreement and understand its terms and hereby agree to them. __________________________________________
Signature of Parent/Guardian __________________________________________
Printed Name of Parent/Guardian __________________________________________
Signature of Child __________________________________________
Printed Name of Child __________________________________________
Address ____________________________Phone ____________________________Date Therapist
Name ________________________________________ Therapist
Address _______________________________________ City, State,
Zip __________________________________________ Phone _________________________________________________ Signature_______________________________________________ I have
received the Parent/Guardian Copy that contains an explanation of the document I have signed and contact information if I
have questions. _______ INITIAL
HERE. PARENT/GUARDIAN COPY Give to parent/guardian upon receipt
of signed authorization forms. The Health Insurance
Portability and Accountability Act (HIPAA) Privacy Regulations USC/WPS are committed
to protecting the privacy of your health information. State law also provides
protections regarding your patient health information. As of Authorization to
Use Health Information This authorization (Authorization
to Videotape form) permits USC/WPS and your attending health care provider to videotape your child. This videotape will be used for educational or instructional purposes only to train course participants. While presenting this video for educational purposes, your health care provider may
also discuss your care and treatment. You understand that your picture, or other
details that would disclose your identity, may be revealed. By signing this authorization
(Authorization to Videotape form), you waive any right to compensation for such uses, and you and your successors or
assigns also release and hold harmless USC/WPS, your attending health care provider, and their Facility from and against any
claim for any injury in connection with the use or display of your image, voice, likeness, or any other identifying characteristics
in the presentation of your videotape, and any compensation resulting from the activities authorized by you in this authorization. How long with this
authorization be in effect? This authorization will
remain in effect indefinitely from the date of signature on the Authorization to Videotape form. What if I have questions
about this authorization?. You may contact either
or both of the organizations involved with the Program: USC - Division of Occupational
Science & Therapy 12031 Wilshire
Boulevard 1540 Alcazar, CHP-133
Los Angeles, CA 90025 Phone: (323) 442-2850
Fax: (310) 478-7838 Fax: (323) 442-1540 Are the individuals
who receive my health information pursuant to this authorization permitted to use or disclose it for other purposes? USC/WPS will not use
or disclose your health information pursuant to this authorization for other purposes except with your written authorization
or as specifically required or permitted by law. However, you understand that
you are consenting to be videotaped and authorizing the disclosure of any health information that will be contained on the
videotape and discussed during presentation for educational or instructional purposes only.
Once disclosed, federal privacy protections would not apply. |
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