Skip to main content

Media Consent Form

Thank you for your interest in sharing your health story with our community. Doing so stands to inform and inspire others, while giving hope to those who are facing similar health challenges. To give Highmark Health permission to share your story and/or photos/videos externally, please review and sign our media consent form.

Fields marked with an asterisk (*) are required.

Please add the name of the person being photographed or recorded:

Please add the name of the parent, legal guardian or representative completing this form (if applicable):

I hereby grant permission to Highmark Health, its subsidiaries, corporate affiliates, officers, employees and agents ("Highmark Health"), to procure, 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 redisclose this material, including, but not limited to, distribution via social media and other advertising channels such as 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.

By signing this form, I hereby release Highmark Health from any liability associated with the procurement, maintenance and distribution of me, my statements 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.)