JRMC Marketing Release Form – Jamestown Regional Medical Center

Your Name *

First

Last

Is this release form regarding yourself? *

YES
NO

Patient's Name *

First

Last

Your Relationship to the Patient *

If Other *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Were you representing a business? *

YES
NO

Business Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Additional Comments

File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Please only submit images you have the rights to. If you have additional images you would like to share, please feel free to send them to info@jrmcnd.com.

Authorization *

I authorize my signature

I authorize Jamestown Regional Medical Center and those acting on behalf of Jamestown Regional Medical Center to photograph, film or record me and use these images or recording in JRMC's marketing. This includes, but is not limited to, print and broadcast media, JRMC's website and newsletters or other social media such as Facebook, Instagram, Twitter, LinkedIn, Pinterest and YouTube. I realize I will not be paid for this service and hereby release Jamestown Regional Medical center, its staff and physicians, from any liability which may result from this content.

Stay in Touch With JRMC *

I'd like to receive information by mail, like JRMC AppleSeeds.
I'd like to receive JRMC Foundation's email updates.
Please remove me from all future Foundation communication.

The privacy provisions of the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) apply to health information created or maintained by healthcare providers who engage in certain electronic transactions, health plans and healthcare clearinghouses. HIPAA governs how healthcare providers like JRMC handle patient information. HIPAA permits JRMC and its institutionally related foundation, JRMC Foundation, to use certain information (e.g. patient ID, name, address, telephone number, dates of service, age and gender) to contact you in the future to raise funds for the benefit of JRMC, provided that patients are given the opportunity to "opt-out" of such fundraising communications.

Patient privacy opt-out is only for past and current patients of JRMC. We will honor your request not to receive fundraising communications from the JRMC Foundation after the date we receive your request.