RULA – FEEDBACK AUTHORIZATION

I give Path CCM, Inc., which does business as Rula (“Rula”), and its related medical groups permission to use and share my feedback for marketing and other business purposes.

My feedback may include information about my health or my experience with care. If my feedback is used in advertising or other public marketing, it will be used in a way that does not show my name or otherwise identify me.

Rula and its related medical groups may share my feedback with their staff and with outside companies that help them collect survey responses, create marketing materials, or support their business operations.

By providing my acknowledgement, I consent to and understand that:

• My Feedback may be used and shared to promote Rula’s products and services.

• Rula may use all or part of my Feedback (for example, short quotes).

• Rula will not condition my treatment on whether I sign this form.

• Giving this Feedback is voluntary.

• I may revoke (take back) this consent at any time by notifying Rula in writing

• My revocation will not apply to any Feedback already used or shared in reliance on this authorization.