Authorization for release of information and\or public use of image (photograph or videotape)

I hereby give consent to participate in a promotional story.

I have been informed that once information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and that I may revoke this authorization at any time by providing notice in writing to the following address: Marketing and Communications, University of Iowa Health Care, 200 Hawkins Drive, E110 GH, Iowa City, IA 52242-1009. The revocation will not affect any actions taken before the receipt of this written notification. Questions? 319-356-1009.

University of Iowa Health Care will not receive, directly or indirectly, financial compensation from a third party for the use and/or disclosure of the health information described above.