Release Consent Form

By signing below, I understand that:

I am giving The Richland Hospital, lnc. (“Hospital”), permission to use and disclose photographs, video, audio recordings, testimonials or other written or recorded statements, information about my health and treatment, my name and other demographic information for future promotional and marketing efforts directed at the public, other health care providers, or others, including, but not limited to, television, radio, internet, newspaper, magazine, or other print advertisements; newsletters; educational materials; mailings; and brochures.

I understand that I will be given a copy of this form after I sign it and that:

1. My participation is strictly voluntary. I acknowledge and agree that I am under no obligation to make this
authorization and that the Hospital has not conditioned any treatment, payment, enrollment, or eligibility of
benefits on my signing this authorization.

2. l will receive no compensation for my participation.

3. This authorization will expire in 100 years unless I revoke it sooner, and the photograph or videos may be retained indefinitely.

4. I am entitled to review any photograph, video, audio recording, testimonial or other written/ recorded
statement prior to the hospital’s use or disclosure and that I may withdraw my consent and revoke this
authorization after such review. In addition, I understand that I may revoke this authorization at any time,
except to the extent that the hospital has already used or disclosed the photograph or other material in
reliance of this authorization. To revoke my authorization, I understand that I must send a written request to:

The Richland Hospital and Clinics
Marketing Department
333 East Second Street
Richland Center WI, 53581

I understand that my revocation is effective only if it is in writing.

5. The information disclosed by the Hospital may be redisclosed and no longer protected by applicable privacy laws.

6. Information may be used and disclosed via a third-party website, such as Facebook, and The Richland Hospital and Clinics has no control over or liability for the privacy and security of information collected or retained by such third parties.

Best way to contact you in case of questions