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I give RWJBarnabas Health permission to contact me about my story.

I consent to the terms and conditions of the HIPAA Authorization and Liability Release form and understand that my information may be used for marketing and public relations purposes.

HIPAA Authorization for Disclosure of Medical Information:

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.