Please read the information below carefully and ask if you have questions about this form or its uses.
Tivity Health Services, LLC (“Tivity Health”) respects the privacy of your information. We would like to use it as described below – if you agree, please complete this form as indicated below.
“I hereby give Tivity Health and its affiliates the right to use my image, photos, verbal statements, recorded statements, or written correspondence obtained by Tivity Health (the “Information”), for any lawful purpose. I understand and acknowledge that the Information I share with Tivity Health may disclose the fact that I am a member of a specific health plan and may contain information regarding me and my experiences with products or services offered by Tivity Health or its affiliates.”