Authorization Form

Public Relations/Marketing/Audio Visual

By filling out this form and clicking submit, I hereby provide authorization to Health Alliance Plan and its subsidiaries, affiliates, agents, and/or the media for this interview, audio/videotaping, and/or photographic session. I grant Health Alliance Plan and its entities the right to use the images and/or recordings for the following purposes:

• Local and national media
• Health Alliance Plan publications
• Other publications
• Advertising/Marketing promotions: TV, radio, billboards, newspaper
• Patient information/education
• Video/audio production
• Internet, including social media platforms (e.g., Facebook, Instagram, LinkedIn, YouTube) and third-party websites

I waive all rights, claims, and interest in all audio/visual recordings and all rights to payment or royalties in connection with their use and/or publication.

I understand that my personal information, including but not limited to my name, likeness, voice, and testimonial, may be used in accordance with applicable privacy laws. Health Alliance Plan will take reasonable steps to protect my personal data and will not disclose it to unauthorized third parties.

I acknowledge that I will not have the right to inspect or approve the final version of any materials produced, including written copy or video/audio content, prior to its use or publication.

I release and hold harmless Health Alliance Plan, its officers, employees, agents, and assigns from any and all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf may have by reason of this authorization. I agree to indemnify and defend Health Alliance Plan against any claims arising from the use of the authorized materials.

If the person involved is under age 18, authorization must be given by the parent or guardian.

Authorization is valid for one year from the date submitted. In the event Health Alliance Plan has used your information in reliance on this authorization, your authorization will be extended to cover the duration of time the project is in production or use.

I understand that I may revoke this authorization at any time by submitting a written request. However, I acknowledge that revocation will not apply to materials already produced or published in reliance on this authorization prior to receipt of the revocation. By submitting this form electronically, I agree that my electronic signature has the same legal effect as a handwritten signature and constitutes my voluntary agreement to the terms outlined above.