I hereby authorize RWJBarnabas Health, Inc. and/or its affiliates, facilities, agents, subcontractors, employees and consent to RWJBarnabas Health (RWJBH) taking and using my (or my child’s) photographs, films, audio and/or videotapes, using and disclosing my name and information for the purpose of public advocacy, outreach, media relations, social media, education and/or research. I understand that I may be identified in any use of the above materials. I realize that I will not be compensated in any way for the use of photographs, films, audio and/or videotapes, or the publishing thereof. I understand that once my health information is used or disclosed, it is no longer protected by state or federal law.

I am not required to sign this authorization. My treatment, payment, benefit eligibility or enrollment activities are not contingent on the signing of this form.

I understand that, unless properly revoked, this authorization has no expiration date. I understand that I may withdraw this permission at any time to prohibit future use of my (or my child’s) image and/or information. To do so, I must send written notice to the Privacy Officer at the RWJBH hospital. However, I understand that this withdrawal would only affect future use and disclosure of my or my child’s information, photographs and images, which have not been previously published.

I represent that I am the above patient’s healthcare agent / guardian / surrogate / parent.

If you are the healthcare agent or guardian, please provide proof of your authority to act on behalf of the patient.