Authorization for Use of Member Testimonial/Opinion Statement

1. I hereby authorize Kohler and Sharecare and any and all of Sharecare’s contractors, subcontractors, partners and joint ventures, and their respective officers, directors, agents, employees, attorneys and representatives (collectively, Sharecare) to use the information described in paragraph 4 of this authorization, including  biographical information, statements made by me and confidential information and testimonial/opinion statements about me or shared by me and all materials created by or for Sharecare that incorporate any of these items (the “Materials”) in communications disseminated by print or electronic media that have been approved by Kohler.

2. In providing this authorization:

I consent to the release of my name, written quotes, still photographs, video and/or sound recordings of me within the scope of this authorization.

3. The information that I authorize Kohler and Sharecare to use and disclose by this Authorization includes information about my personal experiences with and/or opinions related to the Sharecare programs and/or services in which I am and or was enrolled and participated. I waive my rights of prior approval of my testimony/opinion.

4. I hereby authorize Kohler and Sharecare to use and/or disclose, copy, exhibit, publish, distribute, my testimonial for the purpose of marketing. This Authorization includes protected health information (PHI) which may include documents containing diagnosis and treatment information relating to services received from Sharecare and Kohler, that I would otherwise be entitled to keep confidential under state or federal laws or regulations.

5. I have not received any compensation for the use of my name, written quotes or still photographs, video and/or sound recordings of me.  I understand that Sharecare and Kohler may not condition payment, enrollment, or eligibility benefits based on this authorization.

6. My PHI may be shared with others. Therefore federal and state privacy laws may no longer protect my PHI released pursuant to this authorization for my testimony/opinion.

7. I hereby release Kohler and Sharecare from any and all claims that I may have against Kohler or Sharecare for or relating to the use of our information for the purpose described above. This release does not apply to the use of information outside the scope of this authorization, or for uses not approved by Kohler.

8. This authorization shall remain valid for three (3) years from the date signed unless sooner revoked in writing sent by email to:

I agree that any such revocation will not have any effect on actions taken by Kohler or Sharecare in reliance on the Authorization before actual receipt of the revocation by the person identified above.

9. I understand that I may receive a copy of this form if I request one in writing, at the email address listed above.

10. If this authorization is being signed by Member’s/Individual’s legal representative, (other than a parent of an unemancipated child), Sharecare must be provided with a copy of the health care power of attorney or other relevant document designating the legal representative for Member/Individual.

By checking the consent box, I verify that I have read this Authorization, consent to its terms, I am at least 18 years of age, I am competent and understand and acknowledge that checking the box constitutes the legal equivalent to my physical signature. I understand that my signing of this release is voluntary.