hereby authorize the use of photographs, video and/or the public release of information
regarding the donation, recovery and/or transplant of organs and/or tissues by
Donor Network West for permitted uses, e.g., dissemination to Donor Network
West or hospital staff, physicians, health professionals, and members of the
public for educational, treatment, research, scientific, public relations,
marketing, news media, and charitable purposes.
warrant that I am over the age of eighteen (18) and otherwise authorized to
release the use of photographs, video and/or information regarding the
donation, recovery and/or transplant of organs and/or tissues to Donor Network
West for the permitted uses. I authorize
the use or disclosure of such photographs, videos and/or information in order
to assist scientific, treatment, educational, public relations, marketing, news
media, and charitable goals, and I hereby waive any right to compensation for
such uses by reason of the foregoing authorization. I and my successors or assigns hereby hold
Donor Network West, its employees, officers and agents, and their successors
and assigns harmless from and against any claim for injury or compensation
resulting from the activities authorized by this agreement.
may rescind this Authorization up until a reasonable time before any
photographs, video or information are used, but I must do so in writing and
submit it to: Donor Network West, 12667
Alcosta Blvd. Suite 500 San Ramon, CA 94583.
I have a right to receive a copy of this Authorization.
disclosed pursuant to this Authorization could be re-disclosed by the
recipient. Such re-disclosure is in some
cases not protected by California law and may no longer be protected by federal
confidentiality law (HIPAA).