Photo Release Waiver

I authorize the State of Tennessee, Division of Benefits Administration’s Partners for Health and/or Working for a Healthier Tennessee (including its agents and contractors who are properly authorized by the Health Insurance Portability and Accountability Act (HIPAA) to use my photograph, video and/or a narrative about my success in the Partners for Health and/or the Working for a Healthier Tennessee wellness program.

1. I understand the photograph, video and/or narrative provided may be posted on the internet, used in print and video communications, and/or disseminated through various social media to include Facebook, YouTube, Instagram, and other digital or social media outlets.

2. I understand that my photograph, video and/or narrative provided may be used in a Partners for Health and/or Working for a Healthier Tennessee testimonial email blast that will be sent to all state employees as well as health plan members who opt-in to receiving said emails.

3. I understand the information authorized for use may be subject to redisclosure and will no longer be protected under the HIPAA Privacy Rule.

4. I understand this authorization does not include my address, social security number, billing and payment information, and medical records. This information will remain protected under HIPAA.

5. I understand this authorization to use my information for the purpose of the Partners for Health and/or the Working for a Healthier Tennessee may be used for as long as Benefits Administration operates the wellness program as part of its insurance plans or as long as the Partners for Health and the Working for a Healthier Tennessee initiative are in effect, whichever is longer.

6. I understand I can revoke my authorization by sending written notice to: Benefits Administration, Social Media Coordinator, 1900 WRS Tennessee Tower, 312 Rosa L. Parks Avenue, Nashville, Tennessee 37243-1102. However, this revocation will not affect the use of any photograph, video and/or print published, posted, or otherwise distributed before Benefits Administration, Partners for Health and Working for a Healthier Tennessee received the revocation.

7. I acknowledge that my eligibility for any insurance plan operated by Benefits Administration, or any particular benefits or services under the plans will not be affected by whether or not I agree to this release or revoke this authorization.

8. I acknowledge that Benefits Administration, Partners for Health and Working for a Healthier Tennessee will not pay me any money or services for the use of the information subject to this authorization.

9. I hereby release the State of Tennessee and its officers, employees, agents and assigns from and waive all claims, damages, losses and liabilities resulting from the use of the information subject to this authorization.

I have been given the opportunity to carefully review this form and acknowledge that I am voluntarily granting permission for the use of my information.