I, authorize WVU Medicine to photograph, videotape, or write and publish stories about me or my child, and to use these stories, photographs or video in publicizing the work and activities of WVU Medicine hospitals and clinics and University Health Associates.

I also authorize the release of information about my medical care (or that of my child) for publication or broadcast.

This authorization shall expire three years from the date below. I understand that I have the right to stop photography, videotaping or an interview at any time, and to revoke this authorization at any time.

To revoke an authorization, communicate in writing to: Privacy Officer, WVUH Health Information Management Department, P.O. Box 8049 Morgantown WV 26506. Revocation does not affect disclosures made while the authorization is in effect.

I understand that WVU Medicine will not condition my treatment, payment, enrollment or eligibility for health care services on either this authorization or revocation of the same.

Fill out my online form.