Office of Communications & Media Relations
Submit Communications / Media Consent Forms
The Clinical Center Office of Communications and Media Relations uses an NIH approved secure file sharing service called BOX to allow for electronic submission of communications consent forms by patients who are participating in media or external communications opportunities or giving permission for their care providers to speak about their case/care in relation to those communications opportunities.
If you have any questions about how to complete the form or any questions about the release process, please call us at 301-496-2563.
Who should sign?
If the patient is 18 years of age or older, the patient is the only person who is permitted to sign the form. If the patient is under the age of 18, the parent or guardian must sign the form.
There are situations in which this general rule does not apply. For consultation regarding who is authorized to sign the form, contact the Health Information Management Department at 1-888-790-2133.
How do I sign?
Hand-written or electronic signature is required in order for a request to be processed. Unfortunately, digital signatures enabled by certificates cannot be accepted.
How do I upload to BOX?
Drag and drop your file into the box below or click "select files" to choose your document.
In the File Description text box, please provide Media Outlet or Requestor.
Enter your email address (Required).
Select the Upload button once.
You will receive the following message on-screen after the upload has been successful:
Success. Your file has been uploaded, and the owner has been notified.
Autorización para Entrevistar, Grabar, Filmar, y/o Fotografiar a Pacientes en el Centro Clínico con fines de difusión en Medios de Comunicación Externos/ Comunicaciones (NIH 549 Spanish) (NIH Staff Only)
Authorization for the Release of Medical Information (NIH 527) (NIH Staff Only)
NOTE: PDF documents require the free Adobe Reader.
This page last updated on 12/18/2020