Baptist Health 100th Anniversary Memory Box

This form is being used to obtain authorization from you to release to the public photograph(s) and/or information that is related to your care, condition and treatment as a patient of Baptist Health (in response to media inquiries and/or in news releases and reports, publications, marketing materials and/or the website). 

I hereby authorize and permit Baptist Health to take, obtain and make use of photography and publicity of myself and to release information I provide regarding my health, status, care, condition and treatment as a patient of Baptist Health.

• I understand that such photography, interviews and information may be used for inclusion in media reports, Baptist Health publicity materials (advertisements, billboards and publications), the Baptist Health website (baptist-health.com) and other publicity avenues.
• I understand that media reports and Baptist Health publicity materials are widely distributed and made available throughout Arkansas and eastern Oklahoma.
• I understand that once the provided information has been disclosed in accordance with this authorization, it may be further shared/disclosed by individuals or organizations other than Baptist Health.
• I understand that no compensation will be provided to me for this release.
• I understand that I have the right to request cessation of filming or recording after my authorization has been given.
• I understand that this authorization may be revoked by writing to Baptist Health, Marketing & Communications, 9601 Baptist Health Drive, Little Rock, AR 72205.
• I understand that upon revocation, Baptist Health will make reasonable efforts to discontinue the release of this information/photograph whenever possible except where materials are in the process of or have been printed, displayed and/or disseminated to the public.