I agree to be interviewed and filmed, videotaped, recorded, and/or photographed and I give United HealthCare Services Inc. and any of its affiliates (“United”) and any third party approved by United permission to use the following:
• My name, likeness and image;
• My performance, voice, any other indicators of my identity, biographical information; and
• Any statements I make in the audio and/or video recordings, transcripts, and other materials that result from the interview or recording sessions which are referred to above (collectively called “Materials”).
United may use the Materials in any media (including those which may not yet have been developed) for as long as United requires for advertising, marketing, educational purposes, commercial purposes, and/or other promotional purposes.
I confirm that:
• Any statement I make in the Materials will be, to the best of my knowledge, an honest and accurate reflection of my personal opinions and beliefs and I will inform United if at any point in future I believe that is not the case;
• The Materials belong only to United and by signing this document I am transferring to United all my rights relating to the Materials;
• I will not have the right to approve how the Materials are used; and
• I am a legal adult in my state or, if I am a minor, my parent or legal guardian has signed this Release below.
This Release is a legally binding document and I confirm that I will not take any legal action against United regarding my image rights or how the Materials are used, as long as the use is as described in this document.
This Release is governed by and interpreted in accordance with the laws of the State of Minnesota, without regard to its choice of law provisions.
This Health Information Release is for use with individuals that are members of UnitedHealthcare health plans or plans that UnitedHealthcare administers & patients of Optum Care providers (including, but not limited, to MedExpress, LHI, HouseCalls, WellMed, ProHealth, Southwest Medical Associates, AppleCare, Monarch, PrimeCare, Valley Physician Network, Primary Care Associates Medical Group).
This HIPAA Release must be signed if the statements I make or the audio or visual recordings of me (my “Testimonial”), include Personal Health Information AND I am either (i) a United Healthcare member OR (ii) my provider is affiliated with United Health Group. This HIPAA Release concerns protected health information (“PHI”) under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), which I agree to share with United in accordance with the terms of this Release.
Release of My Protected Health Information:
I agree to share PHI with United as part of my Testimonial and I agree that United can use and release that PHI on this basis:
• My permission is voluntary and I may choose not to sign this form. If I choose not to sign this form, I will not be denied treatment, payment for health care services, or enrollment or eligibility for health care benefits.
• I only agree to share the PHI that I disclose as part of my Testimonial. It is my choice whether my Testimonial includes references to substance abuse, psychiatric or mental health care, reproductive health, Hepatitis B or C testing, HIV, and/or other sensitive information.
• I understand that the PHI that I share, as part of my Testimonial, will be shared with third parties by United and that those third parties could further share that PHI, so that it would no longer be protected by HIPAA.
• I may tell United at any time that I have changed my mind and that I want to revoke my permission to use and release PHI. If I decide that, then I must do so in writing by sending a written request to UnitedHealth Group, Attn: Legal Intake, 9900 Bren Road East, Minnetonka, MN 55343. I understand that my decision to revoke my permission will not have any effect on PHI which was released or used by United or by someone authorized by United before it received my written request.
This release will continue in effect until I either revoke my permission or it otherwise expires automatically under state law.