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)

The 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), is a crucial document that enables individuals to grant permission for their image or likeness to be captured and used by Texas Health and Human Services (HHS) for program development, education, and promotion.

This form is typically filled out by residents of SSLCs or patients of SHs who wish to participate in public events, training sessions, or other activities where photography or recording may take place. The authorization grants HHS permission to publish and publicly exhibit the resulting materials, while also relinquishing all rights, title, and interest in the material to HHS.

Key features of this form include the required information for the resident or patient's printed name, signature, date, and guardian/representative's information (if applicable). The form also outlines conditions, such as the right to refuse signing or revoke authorization at any time. Additionally, it specifies that HHS is not responsible for parties not under its control who take photographs or make recordings of individuals participating in public events.

• This form is used when a resident or patient of an SSLC or SH wishes to participate in public events or activities where photography or recording may occur.
• The authorization grants HHS permission to publish and publicly exhibit the resulting materials for program development, education, and promotion.
• The form requires the resident or patient's printed name, signature, date, and guardian/representative's information (if applicable).