Authorization for Use of Member Testimonial/Opinion Statement

1. I hereby authorize the Division of Benefits Administration of the State of Tennessee’s Department of Finance and Administration (“State of TN”) 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 the Division of Benefits Administration.

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 State of TN 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.

4. The information that I authorize State of TN and Sharecare to use and/or disclose by this Authorization includes protected health information (PHI) which may include documents containing diagnosis and treatment information relating to services received from Sharecare under the State of Tennessee Insurance Plans, 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 State of TN may not condition payment, enrollment, or eligibility benefits based on this authorization.

6. Whoever gets my PHI may share it with others. That means federal and state privacy laws may no longer protect my PHI released pursuant to this authorization.

7. I hereby release State of TN and Sharecare from any and all claims that I may have against State of TN 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 Benefits Administration.

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 State of TN 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, and acknowledge that checking the box constitutes the legal equivalent to my physical signature.