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Arkansas Children's Hospital Patients and Families

I authorize the use/disclosure of my protected health information (if such information is included in my submission) as described below:

1.  Who is authorized to use/disclose this information:  Arkansas Children's Hospital

2.  Who is authorized to receive this information:  The public by way of publication including, but not limited to, ACH websites, ACH sponsored social media sites (Facebook, Twitter,, etc.), the internet, newspapers, television and/or radio broadcasts, book, brochures, magazines, motion picture film or video, and photographic displays. This may include use by other organizations ACH may affiliate with on specific projects.

3.  The specific information to be requested or released:

  • Patient's name and medical case study (if submission is a medical story).

  • Any quotation or comment (made verbally, in writing, or video/audio tape recorded) by the patient and/or concerning the patient and my medical story.
  • Pictures or video/audio of the patient that may be taken and reproduced for use.

4.  I understand that if the person or entity that receives the information is not a health care provider, the information described above may be redisclosed and no longer protected by the privacy regulations.

5.  I understand that neither the patient nor his or her personal representative will be paid any publication (web/print/broadcast) fees.

6. I understand that by submitting this story, images, video, audio, etc., that I am sole owner/author of the materials - none of which are copyrighted (example – I am submitting photos shot by me, not a professional photographer/portrait studio) - and am providing Arkansas Children’s Hospital its right to publish and attribute to me. I may inspect or obtain a copy of any information used/disclosed under this authorization.

7.  This authorization expires ten (10) years from the date of submission/authorization unless revoked by me. I understand that I may revoke this authorization at any time by delivering a copy of my revocation to Arkansas Children's Hospital Public Relations department except to the extent that action has been taken in reliance on this authorization.

8. I understand that beyond my first name, city and state, none of the contact information I provide (phone, mailing address, e-mail, fax) will be disclosed, but Arkansas Children's Hospital Public Relations department may need to contact me before publishing my story. I understand that Arkansas Children's Hospital cannot publish all stories that are submitted and I am aware that there is no guarantee that my story/submission will be published.

9. If my story contains health information, I acknowledge that by checking the box below that I am the patient (age 18 or over) or the legal representative of the patient (if a minor).

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