Saint Peter's Delivers!
Fill out this form and upload your baby’s photo for the opportunity to be randomly selected to be featured on our billboard.
Fill out this form and upload your baby’s photo for the opportunity to be randomly selected to be featured on our billboard.
We know the joy of being a new parent and want to give you the opportunity to share news of the birth of your Saint Peter’s baby.
Agree to the terms below and follow the simple steps to upload a photo of your new baby born at Saint Peter's. Your photo announcement may be randomly selected to appear on a Saint Peter's billboard and on our social media platforms.
Photograph/Interview Consent and Authorization to Disclose/Release Protected Health Information for Marketing, Media, Education or Charitable Purposes
I give Saint Peter’s Healthcare System (“Saint Peter’s”), New Brunswick, NJ, my consent to use those photographs/recordings/videos or interviews and other information about me/my child, as noted below. I understand that photographs/recordings/videos or interviews may be considered “protected health information” (PHI), protected by federal privacy laws.
I give Saint Peter’s Healthcare System my consent to use photographs/recordings/videos or interviews and other PHI about me/my child for the following purposes:
This consent to release photographs or other PHI about me/my child will be good for one (1) year from the date of this consent.
I understand that I have the right to revoke this authorization at any time. I can do so by submitting my revocation in writing to the Marketing and Media Relations Department at Saint Peter’s Healthcare System, 254 Easton Avenue, New Brunswick, NJ 08901. I understand that my revocation will not apply to information that has already been released in response to this authorization.
I understand that cancelling this release will have no effect on PHI already released before my letter is received by Saint Peter’s. I also understand that once my photographs or other PHI have been distributed, Saint Peter’s will not be able to withdraw them from circulation. I understand that once the photographs or other PHI is released by my signing below, the information might be re-released and no longer protected by federal privacy law.
I understand that Saint Peter’s Healthcare System will not receive any payment by using this photograph or any other PHI.
I understand that I may refuse to sign this release, and that my refusal will not affect my treatment at Saint Peter’s Healthcare System.
254 Easton Ave New Brunswick, NJ 08901
254 Easton Avenue
New Brunswick, NJ 08901
732-745-8600