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Testimonial Consent and Release Form (“Release”)

Purpose of Release: The purpose of this Release is to give your permission to OptumHealth Care Solutions, Inc. and its affiliates, successors and assigns (collectively, “Optum”) to use your information (“Testimonial”) for advertising, publicity, educational, and promotional purposes and any other purpose, on behalf of itself or third parties, as Optum deems fit and appropriate.

You agree as follows:

1. Your Testimonial. Your Testimonial includes all items and/or information you specifically give to Optum (for example, your name, quotations, personal information, photos, success stories, etc.) as well as all things you let Optum record (for example, your voice, video footage, photos, etc.). The Testimonial is a true expression of your real experience, honest feelings, and/or beliefs. You agree that the Testimonial is not in any way false or misleading. Your information includes the following:

Check applicable boxes:

2. You understand and agree that Optum has the unrestricted and unending right to:

(a) Reproduce, copy, modify, create derivatives of, or use the Testimonial, and
(b) Use your name in connection with the Testimonial as Optum may choose, and
(c) Display, distribute, send or broadcast the Testimonial by any means or method.

You give Optum your permission to use your Testimonial for the purpose of creating, publishing and distributing promotional, educational, advertising and publicity materials (the “Published Materials”). Optum shall be the copyright owner of all Published Materials, and you give Optum, absolutely and forever, the copyright and the right to secure copyright of the Published Materials and all extensions and renewals of such copyright. You agree that no promotional idea or document containing the use of the Published Material needs to be submitted to you for review or approval, and waive any right to compensation of any sort related to Optum’s use of the Published Materials.

3. Optum has no obligation to use this permission. The terms of this permission shall begin on the date you have signed below.

4. You agree to waive all rights and release Optum from, and shall not sue Optum or take any other legal against Optum for, any claim or cause of action, whether now known or unknown, including without limitation, for defamation, invasion of right to privacy, publicity or personality or any similar matter, or based upon or relating to the use and exploitation of the Testimonial.

I have read this Release, understand it, and am signing it voluntarily. I understand that any consideration received is full and fair for purposes described above for the use of the Testimonial. By my signature, I represent that I am at least eighteen years of age and am free to execute this Release.

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