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 that right to use the images for these purposes:

• Local and national media
• Health Alliance Plan
• Other publications
• Advertising/Marketing promotions: TV, radio, billboards, newspaper
• Patient information/education
• Video/audio production
• Internet

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

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

Authorization is valid for one year from 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. This authorization may be revoked at any time. However, to the extent Health Alliance Plan has used your information in reliance on this authorization, revocation may not be possible. Revocation to this authorization must be in writing.