Please read the information below carefully and ask if you have questions about this form or its uses. If you choose not to sign this form, your decision will have no effect on your medical care, payment for your care, or the health benefits you receive.

Healthways, Inc. and Group Health Cooperative respect the privacy of your information. Healthways, Inc. and Group Health Cooperative request your consent to use your story for purposes not related to your medical treatment or care.

I hereby give Healthways, Inc. and Group Health Cooperative, their assigns, licensees, and legal representatives the irrevocable right to use my photos, verbal statements, taped statements, or written correspondence in whole or in part, in all forms of media and in all manners, including advertising, trade, or any other lawful purposes, and I waive any right to inspect or approve the finished product, including written copy, that may be created in connection therewith.

Such photos, verbal statements, taped statements, or verbal correspondence may disclose directly or through inference the fact that I am a member or patient of Group Health Cooperative and may contain other information about me, including private health information.