Your first and last name *

Your baby's first name (Or names if you have twins, triplets, etc) *

Your baby's date of birth *

Hospital where your baby was born *

I hereby authorize WellSpan Health and/or any affiliated entity to use or disclose protected health information about my child in photos (digital or still photography, slides) and print and digital media (newspapers, magazines, brochures, Web, social media, etc.).

The photos may be used or disclosed for WellSpan Health publications, medical or other hospital publications, general circulation newspapers and magazines, brochures, television programs or commercials, Internet sites, social media platforms or exhibits.

I may revoke this authorization by notifying the WellSpan Health Privacy Office at privacy@wellspan.org, in writing, of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

I understand the following:

• The information used or disclosed may be subject to re-disclosure and would no longer be protected by federal privacy provisions.
• I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or my eligibility for benefits.
• I will not receive compensation in any form for the use of these photos and print and digital media.

This authorization expires on January 31, 2025.

My signature acknowledges that I have read and understand the content of this authorization, and all of my questions have been answered.

Authorization for photography use for public relations and marketing

Type your first and last name *

Upload photo 1 *

Upload photo 2

Upload photo 3

You can send up to three photos, though only one picture of each child will be used. Not all pictures will be shared, and all submitted photos will be screened before use.