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 used to obtain permission from individuals to photograph or record them for the purposes of program development, education, and promotion. This form helps solve the problem of obtaining informed consent from individuals who wish to be photographed or recorded by Texas Health and Human Services (HHS) programs.

This authorization form requires the individual's printed name, signature, date, and guardian/representative information if applicable. The form also highlights key features such as the right to refuse signing, revocation of authorization at any time, and expiration of the authorization after three years unless renewed. Common scenarios of use include public events, training, education, and local news promotion.

The form explicitly mentions that HHS is not responsible for parties not under its control who take photographs or make recordings of individuals who voluntarily participate in public events. Additionally, it notes that revocation or expiration of the authorization does not mean that HHS will remove previously created materials featuring the individual's photograph or recording.