*First Name *Last Name *Phone Number *Email *Address *City *State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming *Zip *Select Facility Barnabas Health Ambulatory Care Center Childrens Hospital of New Jersey at Newark Beth Israel Medical Center Childrens Specialized Hospital Clara Maass Medical Center Community Medical Center Cooperman Barnabas Medical Center Jersey City Medical Center Monmouth Medical Center Monmouth Medical Center, Southern Campus Newark Beth Israel Medical Center Rutgers Cancer Institute of New Jersey RWJ University Hospital Hamilton RWJ University Hospital New Brunswick RWJ University Hospital Rahway RWJ University Hospital Somerset RWJBarnabas Health RWJBarnabas Health Behavioral Health Center RWJBarnabas Health Medical Group The Bristol-Myers Squibb Childrens Hospital at RWJUH The Unterberg Childrens Hospital at Monmouth Medical Center Trinitas Regional Medical Center 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. Agree Agree *Signature *Are you a personal representative? YesNo I represent that I am the above patient’s healthcare agent / guardian / surrogate / parent. *Personal Representative First Name *Personal Representative Last Name *Phone Number *Address *City *State *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming *Zip *Personal Representative Signature If you are the healthcare agent or guardian, please provide proof of your authority to act on behalf of the patient. Proof of authority