AUTHORIZATION FOR MEDIA AND PUBLICATION: By signing this form, I give my consent to West Virginia United Health System, Inc. (“WVUHS”), and its subsidiaries and affiliates, including but not limited to West Virginia University Hospitals, Inc. (“WVUH”), to photograph, record, videotape, write, or publish retain ownership and use or license for use in its sole discretion all photographs, recordings, and/or video images obtained (“media”) of me (or the patient, if applicable). I understand that the media obtained may relate to my (or the patient’s) personally identifiable health information and/or medical care and treatment.

I understand that this authorization is voluntary and hereby waive any right to compensation for such uses authorized by this authorization. I also waive any right to inspect or approve the finished media prior to utilization and I waive any right to royalties or other compensation arising from or related to the use of this media. I understand that my decision to consent to use of this media in no way impacts my medical care or treatment.

I understand that for promotional purposes, including stories or advertisements, media will appear in the public domain and may be used more than once by WVUHS and/or its subsidiaries.

This authorization shall expire three (3) years from the date below. I understand that I can revoke this authorization at any time by communicating the revocation in writing to: Enterprise Director of Privacy, Enterprise Information Management, P.O. Box 8300, Morgantown WV 26506. I understand that revocation does not affect media obtained while the authorization is still in effect and that anything obtained while this authorization is in effect is the property of WVUHS and its subsidiaries and affiliates and can be used by WVUHS and its subsidiaries and affiliates in their discretion. I also understand that I have the right to stop photography, filming, videotaping, recording and/or an interview at any time notwithstanding this authorization.

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