I 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.
I 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.
I 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.
Information 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).