Beacon Health System Form Site | Patient submittal form

Seeking patient video content or photos

Beacon Marketing is seeking video footage or still photos of patients to be used for marketing purposes. We would accept content of patients at our facilities, with their providers, or recovering at home. Uses of your footage could include, but would not be limited to: as an addition to video projects, used with social media posts, accompany web stories, used as part of digital ads, etc. If you have content you would be willing to share, please complete this form.

Marketing – Patient Submittal form

Name*
First Last
Phone*
Email*
Name of provider
Date of service
I have video footage to share.
- Yes
- No
I have photos to share.
- Yes
- No
Service*
CAPTCHA
Consent*
I agree to the privacy policy.
I hereby authorize Beacon Health System to use my personal, provided content, as indicated by checkmark:

Photographs or video footage of me as a current or former patient, or a participant in a Beacon Health System program, for use by Beacon in all or any of the following: video projects, used with social media posts, accompany web stories, used as part of digital ads publications, audio-visual presentations, fundraising materials or for print, web, including social media or broadcast media.
[radio button] I have read and agree to the terms and conditions in this consent form.

I understand that I may refuse to sign this Authorization and that Beacon Health System will not condition treatment, payment, enrollment in the health plan or eligibility for benefits on the provision of this Authorization.

This authorization is valid until revoked by the patient or an authorized representative. I understand that I have the right to revoke this authorization, except if Beacon has taken action in reliance upon it. My revocation must be delivered, in writing, to Beacon Marketing, 615 N. Michigan, South Bend, IN 46601.

I understand that images or information disclosed under this Authorization may be disclosed by the recipient and the information will no longer be protected by the privacy law.