Photo, Video and Audio Release

I, the undersigned, authorize Group Health Cooperative of South Central Wisconsin (GHC-SCW) to disclose to media representatives and/or public affairs/relations representatives protected health information and information about me, my condition and/or treatment for purposes of publications, fundraising, advertising, marketing, research/educations programs, publicity, promotion, education or publication in print, broadcast and electronic media, including social media. This authorization includes my likeness on photo, videotape and digital media.

This authorization also allows the media/public affairs/relations representatives to take photographs, films, audio and/or videotapes, interview me or publish information about me, and to use my likeness and information in an appropriate manner for the above project.

I consent to the taking and use of the photographs, films, audio and/or videotapes, or other materials as described above. I understand that I may be identified in any use of the above materials. I realize that I will not be compensated in any way for the taking or use of photographs, films, audio and/or videotapes, or the publishing thereof. I understand and agree that this Authorization is valid for ten (10) years unless I cancel it in writing (as described in the next sentence). I understand that I may cancel this Authorization at any time by sending written notice to GHC-SCW at:

GHC-SCW Marketing Department
1265 John Q. Hammons Drive
Madison, WI 53717

I understand that once my health information is used or disclosed, it is no longer protected by state or federal law.

I understand that I am signing this Authorization of my own free will, and that GHC-SCW cannot require I sign this Authorization as a condition for getting treatment, making payments on any bills, or gaining enrollment or eligibility in any health insurance plan, unless Federal Privacy Regulations allow. I have a right to inspect and copy my own protected health information to be used or disclosed in accordance with the Notice of Privacy Practices. A copy of GHC-SCW’s Notice of Privacy Practices is available at www.ghcscw.com.

I understand that I am entitled to a signed copy of this Authorization.

If participant is under age 18:

I am the parent or legal guardian of the minor named above and authorize GHC-SCW to use the minor’s image, likeness, voice, name and/or statements as described in this release.