Authorization for Release of Information – Marketing Purposes

I consent to the taking and use of the photographs, films, audio and/or videotapes, or publishing of the attached article or information as described above, including placement in a central repository for storage so that any BJC-affiliated healthcare provider may reuse my photograph or video at any time in the future unless I specifically decline as indicated above. 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 taking or use of photographs, films, audio and/or videotapes, or the publishing of the attached article or information. I understand and agree that this Authorization is valid unless I cancel it in writing (as described in the next sentence) for as long as the Organization noted above (or any organization that succeeds it) stays in business. I understand that I may cancel this Authorization at any time (as long as the Organization noted above has not taken action in reliance on this Authorization) by mailing, faxing, or bringing a letter in person to the organization indicated above. I understand that once my health information is used or disclosed, it is no longer protected by state or federal law. I understand that neither BJC HealthCare nor any of its affiliated healthcare providers can make me sign this Authorization as a condition to getting treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless the Federal Privacy Regulations allow it. I understand that if the Organization noted above will receive money or other compensation (either directly or indirectly) from someone else because of the use of my health information in the project described above, I have been told of the compensation. I agree that I have received a signed copy of this Authorization.