I hereby authorize Workit Health to use and/or disclose my name, images and/or health or personal information.

The following information can be used and/or disclosed: (check all that apply)

• Any information obtained during an interview, including, but not limited to, health information, personal information and/or testimonial (e.g., patient, student, donor, employee)
• Photographs or other images

I authorize Workit Health  to disclose the information (as described above) to the public through any form of media (e.g., university publication, newspaper, TV, magazine, Internet, film, etc.), or as otherwise specified below.

I understand the purpose(s) of the requested use or disclosure is (are) as follows:

• General publicity or marketing, including fundraising, recruitment and advertising materials
• Workit Health publications and/or digital outlets (e.g. www.workithealth.com, social media)
• News related to TV, radio or print media inquiries

I understand this authorization is voluntary and I may refuse to sign. If I am a patient, Workit Health may not withhold treatment based on the completion of this authorization.

I understand that I may revoke this authorization at any time by notifying in writing and expressing to Workit Health’s Office of Marketing and Communications, 3300 Washtenaw Ave. Ste. 280 Ann Arbor, MI 48104 of my intent to revoke this authorization. I understand that such a revocation will have no effect on information already used or disclosed by Workit Health prior to Workit Health’s receipt of my written notice of revocation.

Unless otherwise revoked, I understand that this authorization will expire when the information is no longer useful to the education, patient care or research missions of Workit Health, at which time the information will be destroyed.

I understand that the information disclosed pursuant to this authorization may be re-disclosed by the end user (e.g., media outlet) and no longer protected by federal or Michigan privacy laws.

I release Workit Health and its officers, agents and employees from any and all liability connected with use or disclosure of this information in the media application(s) listed above.

I give my consent in the interest of public information, for the furtherance of education, patient care and the research goals of this institution, or for other lawful purposes.

I waive all rights, interest or claims for payment in connection with any exhibition or release of this information in the media application(s) listed above.

If I am being treated for drug or alcohol abuse, a mental health or psychiatric disorder, or acquired immunodeficiency syndrome or human immunodeficiency virus, I understand that information regarding my condition may be used.

I understand that Workit Health may choose to copyright images or printed matter for its own benefit and may decide to protect unauthorized users from further using or reproducing the images or printed matter.

*Note: Contact Media Relations office at 855-659-7734 for assistance with media inquiries

**Responsible for (1) ensuring form is kept on file according to state records-retention guidelines and (2) ensuring a copy of form is provided to individual or guardian named above