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Methodist Health System Authorization to use Patient Information, Photographs and Video

I authorize Methodist Health System (MHS) and Methodist Physicians Clinic (MPC) Bariatric Surgery to share my story, photographs and video that I uploaded to the MPC Bariatric Surgery website for marketing purposes. I understand that "marketing purposes" includes, but is not limited to, the MPC Bariatric Surgery website, MHS website and other MHS and/or MPC marketing publications.

I understand that only the information that I have uploaded will be shared and that none of my information will be released without my written consent as provided on this Authorization.

I understand my information will be used for marketing purposes.

I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to the MHS Vice President of Marketing.

Methodist Health System and its affiliates cannot condition treatment based on authorization for disclosure of information. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected.

I agree