Authorization to Use and Disclose Information for Communications and Marketing

This form authorizes us to use and disclose your health information or that of your loved one as described below.

Your Name:

Your Date of Birth:

Donor's Name:

Today's Date:

Who can use and disclose information: LifeShare Carolinas, and its agents, affiliates, associated foundations, and locations.

Types of information we can use and disclose: You give LifeShare Carolinas permission to use and disclose any health information in any form (print, photograph, audio/oral, interview, video, digital, televised, posted, streamed, and other electronic forms), that we think is relevant, including your name or your loved one's name, age, city of residence, illness/injury, yours or your loved one's story, and yours or your loved one's image, including any photographs, videos, or recordings in which you or your loved one appear.

Note: In order to authorize release of your loved one's information, you must be the personal representative of the estate - either designated by a will or appointed by a court. If there is no estate, you can signify by signing and having notarized an affidavit stating there is no personal representative and that you are the next of kin. LifeShare Carolinas can disclose yours or your loved one's information to: local, regional, or national media outlets, including on social media; the public; LifeShare Carolinas marketing and communication recipients; associated foundations; and other third parties designated by LifeShare Carolinas.

What we can do with yours or your loved one’s information (purpose): LifeShare Carolinas can use and disclose your information to share yours or your loved one's story internally and externally, to market LifeShare Carolinas and promote our services, to educate others about organ, eye, and tissue donation, and to publish articles and give presentations. We may communicate this information in newspapers, magazines, and other publications; radio, podcast, and television broadcasts; internet and intranet sites; marketing and public relations materials/publications; social media outlets; and in patient or public education materials and brochures.

With whom we can share yours or your loved one’s information: LifeShare Carolinas can disclose yours or your loved one's information to: local, regional, or national media outlets, including on social media; the public; LifeShare Carolinas marketing and communication recipients; associated foundations; and other third parties designated by LifeShare Carolinas.

How long this authorization lasts: This Authorization will expire when LifeShare Carolinas no longer needs the information. Please note that uses and disclosures involving this information made or issued before the expiration date cannot be retracted, especially if they were already released publicly.

Please also understand that:

You can cancel this Authorization at any time by sending written notice to LifeShare Carolinas Community Services Department, PO Box 32861, Charlotte, NC 28232. Cancellations will apply only to information not yet used or disclosed by LifeShare Carolinas. Note that once LifeShare Carolinas uses and discloses your information, the person or entity receiving it may disclose or share that information with others and it may no longer be protected by federal and state privacy protections.
LifeShare Carolinas will not share or use your health information without your authorization other than as required by law or in the ways listed in the Notice of Privacy Practices, available at www.LifeShareCarolinas.org.
You have a right to receive a copy of this form upon request.

FOR DONOR FAMILIES:

Please check this box if you are signing as the personal representative of a donor.

NOTE: If the patient is a minor, lacks legal capacity, or is unable to sign, an authorized personal representative may sign this form. Note the relationship/authority if signing on behalf of someone.

Parent

Guardian

Patient/Minor's Name:

Leave this empty:

Your legal name

Your email address