TX HHS Form 5402. Office of Communications Media Release

The TX HHS Form 5402, Office of Communications Media Release, is a crucial document for individuals who need to grant permission for photography, audio, or video recording by Texas Health and Human Services (HHS) for program development, education, and promotion purposes.

This form serves as an authorization for HHS to capture visual and auditory content of the individual, which can be used in various materials such as publications, exhibitions, and online platforms. The document outlines the conditions under which the individual grants permission, including the right to revoke this authorization at any time by delivering a written and signed statement to the HHS Office of Communications.

The form requires specific information from the individual, including their printed name, contact phone number, email address, and signature date. Additionally, for minors or incapacitated adults, consent must be provided by a parent or guardian, who must also provide their printed name, relationship to the subject, area code and phone number, email address, and signature date.

• This form is typically used in situations where HHS needs to capture visual and auditory content of individuals for program development, education, and promotion purposes.
• The individual has the right to refuse or revoke permission at any time.