Media Consent Form

I hereby grant permission to Highmark Health, its subsidiaries, corporate affiliates, officers, employees and agents ("Highmark Health"), to procure, edit, maintain and distribute photographs, social media posts, statements, video and/or voice recordings of me for use in promotional, marketing, publication and/or educational materials and/or speak on my behalf and provide information and the above-listed materials (which may include information about my health) to news media representatives that have been approved by the Highmark Health public relations team. I acknowledge that this authorization includes use of these materials by Allegheny Health Network and its subsidiaries, corporate affiliates, officers, employees and agents.

Highmark Health may subsequently edit and/or redisclose this material, including, but not limited to, distribution via social media outlets and other advertising channels such as websites and bulletin boards. I understand that these photographs, statements or recordings may include protected health information (PHI), and potentially, information related to sensitive diagnoses, including but not limited to, behavioral health, substance use disorders, and/or HIV/AIDS. This PHI will no longer be protected under the Health Insurance Portability and Accountability Act (HIPAA) or applicable state or federal laws when the information is made public or shared with certain third parties. I understand that I have no right to inspect or approve the finished materials or final product. I further understand that I have no property right in any of the photographs, statements or video/voice recordings taken of me, and that I will not be compensated for the same. I also understand that the materials may be edited or modified by Highmark Health or its designee, and that such editing and modification may be supported by or otherwise use artificial intelligence and related technologies (“AI Technologies”) and I hereby give my express written consent, authorization and permission to use such AI Technologies when editing or modifying the materials.

By signing this form, I hereby release Highmark Health from any liability associated with the procurement, maintenance, modification and distribution of me, my statements or my image or my likeness in any photograph, video or voice recording. This permission does not expire. This permission will remain in force until I withdraw it in writing and deliver the written withdrawal to the Highmark Health Strategic Marketing Department at 120 Fifth Avenue Place, Suite 1277, Pittsburgh, PA 15222. Any uses or distributions prior to such a withdrawal, such as a continuing advertising campaign that began prior to receipt of the withdrawal of permission, will continue. I understand that signing or not signing this document will not affect the medical treatment or other benefits or services for which I am eligible or that I receive in any way.

Signature of consenting individual, parent, legal guardian or representative. (By typing your name, you are agreeing digitally to the terms of the media consent form for Highmark Health.)