I hereby voluntarily agree to have my photo and/or video taken by Advance Care Alliance of New York, Inc. (ACA/NY), a NYS designated Care Coordination Organization/Health Home.

I hereby authorize ACA/NY to use my photograph and/or video recording in its newsletters, brochures, social media and/or on its website.

I hereby voluntarily agree to be interviewed by Advance Care Alliance of New York Inc. (ACA/NY), a NYS designated Care Coordination Organization/Health Home

I hereby authorize ACA/NY to include my comments from the interview in its newsletter, brochures, and/or on its website. I understand that ACA/NY will only use my first name. I further understand that to the extent that I have provided information about my health, treatment or my healthcare providers, such information may also be included in ACA/NY newsletters, brochures and/or on the ACA/NY website.

I understand that I may revoke this authorization by notifying ACA/NY at incidentmanagement@myacany.org. If I revoke my authorization ACA/NY will remove from its
newsletters, brochures, social media and/or on its website, my photograph and any article that
contains identifying information about me. I understand that any published information may have been re-published by a recipient of the information which is beyond the control of ACA/NY.

I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or eligibility for benefits.