TX HHS Form 5401. Media Release Authorization to Photograph or Record a Resident of a State Supported Living Center (SSLC) or Patient of a State Hospital (SH)

Form 5401 is an official authorization used by Texas Health and Human Services (HHS) to obtain consent for photographing, audio recording, or video recording a resident of a State Supported Living Center (SSLC) or a patient of a State Hospital (SH). This form protects individual rights while allowing HHS to use media materials for specific, limited purposes related to public programs.

Purpose of Form 5401

The primary purpose of Form 5401 is to document informed consent. By signing this form, an individual—or their legal guardian or representative—allows HHS to create and use photographs, audio recordings, or video recordings for clearly defined, non-commercial uses.

Importantly, signing this form is voluntary. Refusing to sign does not affect medical treatment, benefits, or payment processing.

Who This Form Applies To

• Residents of a State Supported Living Center (SSLC)
• Patients of a Texas State Hospital (SH)
• Parents or legal guardians acting on behalf of residents or patients
• Authorized representatives with a documented legal relationship

When This Authorization Is Required

Form 5401 is typically required when HHS plans to photograph or record individuals for:

• Training and educational materials
• Public information campaigns
• Local news coverage or program promotion

This form is not required for incidental recordings made by third parties at public events outside HHS control.

Explanation of Key Sections

Grant of Permission

This section confirms that the individual grants HHS permission to photograph and record them for approved program-related purposes. It also allows HHS and its authorized partners to publish and display these materials lawfully.

Use of Media Materials

The form clearly limits use to training, education, public information, and promotion. It does not authorize unrelated or commercial use.

Ownership of Materials

All photographs and recordings become the exclusive property of HHS. The signer relinquishes rights to control, reuse, or demand removal of materials created during the authorization period.

Right to Revoke Authorization

The resident, patient, parent, or guardian may revoke consent at any time by submitting a written, signed statement to the relevant SSLC or State Hospital.

Expiration of Authorization

The authorization expires three years from the signing date unless revoked earlier. It may be renewed for an additional three years with newly dated signatures.

Legal and Regulatory Context

Form 5401 supports compliance with Texas Health and Human Services policies governing privacy, consent, and ethical use of media involving vulnerable populations. It reflects informed-consent principles aligned with state regulations for healthcare and residential facilities.

While revocation limits future use, materials created while the authorization was valid may remain in circulation. HHS commits to making reasonable efforts to stop using such materials in new content after revocation or expiration.

Practical Tips for Completing the Form

• Print names clearly to avoid identification issues.
• Ensure the correct SSLC or State Hospital name is listed.
• If signing as a guardian or representative, confirm your legal relationship is accurate.
• Keep a copy of the signed form for personal records.

Common Mistakes to Avoid

• Assuming the authorization is permanent—it expires after three years.
• Believing revocation removes previously created materials.
• Failing to submit revocation in writing.
• Signing without understanding the scope of permitted use.

Real-Life Usage Examples

• A state hospital records a training video that includes patients participating in supervised activities.
• An SSLC photographs residents for an internal educational presentation.
• HHS uses approved footage to explain services in a public awareness campaign.

Documents Commonly Submitted with Form 5401

• Proof of guardianship or legal representation (if applicable)
• Facility intake or identification records

Frequently Asked Questions

Is signing Form 5401 mandatory?

No. Participation is voluntary, and refusal does not affect services or benefits.

Who can revoke the authorization?

The resident, patient, parent, or legal guardian may revoke consent in writing at any time.

Does revocation remove existing photos or videos?

No. Materials created while the authorization was valid may still exist, though HHS limits future use.

How long is the authorization valid?

Three years from the date signed, unless revoked earlier.

Can the authorization be renewed?

Yes. It may be renewed for an additional three-year period with new signatures.

Does this apply to public events?

No. HHS is not responsible for recordings made by third parties at public events.

Micro-FAQ

• Purpose: Allows HHS to photograph or record residents or patients for approved uses.
• Who files: Resident, patient, parent, or legal guardian.
• Deadline: No fixed deadline; authorization expires after three years.
• Attachments: Guardianship proof if applicable.
• Submitted to: Relevant SSLC or Texas State Hospital.

Related Forms and Documents

• Texas HHS Consent and Authorization Forms
• Guardianship Documentation Forms
• Patient Rights and Privacy Notices

Form Details

• Form Name: Media Release – Authorization to Photograph or Record
• Form Number: 5401
• Issuing Authority: Texas Health and Human Services (HHS)
• Applies To: State Supported Living Centers and State Hospitals
• Revision Date: November 2019