Corewell Health Adult Medicine Update 2024- Value, Population Health and the Future of Medicine

AUTHORIZATION FOR THE USE OF PERSONAL IMAGE

By signing in the box, I acknowledge, understand and agree to the following:

1. I hereby authorize Corewell Health and its employees, agents, and affiliates an unlimited right to make, take, use, create, re-create, modify, record, transmit, preserve, produce or reproduce and publish, exhibit, televise, display, or otherwise make available to others, images or likenesses of my face, body and/or voice, by any means including without limitation photograph, video, digital imagery, or other media not yet named or developed, in any Corewell Health related book, magazine, journal, publication, exhibit, newspaper, website, poster, ad, television spot, billboard, or other communications format.

2. Corewell Health’s rights with respect to this Authorization will continue until this Authorization is terminated by Corewell Health or me.

3. I understand that the purpose of this Authorization and the use of my personal image may include all or any one of the following:

- to generate coverage in print, electronic, and other media formats;
- to inform the general public (including the media) regarding various topics or events related to or hosted by Corewell Health and/or its affiliates; and for purposes of promoting Corewell Health and it’s products, events and/or services.

4. I do not place any limitations on the use or disclosure of my personal image.

5. I understand that I may refuse to sign this Authorization and that my relationship or employment with Corewell Health will not be affected by any such refusal.

6. I understand that I have the right to revoke this Authorization, if the revocation is in writing, except if Corewell Health has taken action in reliance upon this Authorization.

7. I understand that in order to revoke this Authorization, I must submit a request in writing to: Corewell Health System Director, Privacy and Information Security at 100 Michigan Street NE, MC 843, Grand Rapids, MI 49503, or via e-mail at patient.privacy@spectrum-health.org.

8. I understand that if my personal image is used or disclosed pursuant to this Authorization that it may also be subject to re-use and re-disclosure by the party or media outlet receiving the information, and such use or disclosure will not be protected by the law.

9. I acknowledge that I have read and understand this Authorization. Further, I authorize the use or disclosure of my personal image in accordance with the terms of this Authorization.

10. I am at least 18 years old.