Video, Photographic and Quotation Consent and Release

I give permission for Fresenius Medical Care Holdings, Inc. d/b/a Fresenius Medical Care North America and its parents, subsidiaries, affiliates, successors and agents (“FMCNA” or “the Company”) or other third parties designated by FMCNA to photograph, videotape and/or record me or use my likeness for commercial purposes, including potentially disseminating materials and communications about me in e-mails, trainings, publications, newsletters, news media, websites, and social media, whether internal or external.

I understand this may include FMCNA’s or the designated third party’s use or disclosure of my name, voice, statements, photograph, videotape, audio recording, likeness or other identifiable information about me. This information about me may be distributed to employees, patients and partners of FMCNA, as well as to members of the public. If I am or was a patient of FMCNA, this may include information about my health care, my experience with FMCNA, and any other personal information I choose to disclose. FMCNA may ask me to execute a separate HIPAA authorization for FMCNA’s use or disclosure of my Protected Health Information if required by law. My treatment will not be impacted if I decline to execute this Consent or a HIPAA authorization.

I further consent to FMCNA’s or the designated third party’s copyrighting, editing, duplication and distribution of materials and communications containing this information. I acknowledge and agree that FMCNA or the designated third party shall have sole and exclusive ownership of any recordings and materials and communications in which I appear, including derivatives thereof and any related copyright interests.

I release and discharge FMCNA (including its directors, officers, employees, agents and representatives) and the designated third party from any liability by virtue of any claims that may arise from such photography, videotaping or other recording, including any blurring, distortion, alteration, optical illusion, or use in composite form that may occur or be produced through completion of the finished product.

I understand that I may not receive credit, acknowledgment or monetary/financial compensation from FMCNA or the designated third party, now or in the future, for the use of my name, voice, statements, photograph, videotape, audio recording, likeness or other identifiable information about me unless specifically agreed in writing.

If I am a California resident, I may refer to the “Special Instructions for California Residents” section of the FMCNA Website Privacy Notice (https://freseniusmedicalcare.com/en-us/privacy-statement/) for additional information about the California Consumer Privacy Act (CCPA) and how certain personal information is collected, used and disclosed, where applicable.

I have read this consent and understand its contents. This consent is not restricted by time or geographic limitation.

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