I hereby give my consent for Iowa Lions Eye Bank to share my story in publications, on its website, via social and news media and at public events. I have been informed that my story may be edited prior to publication.
I hereby give my consent to participate in a promotional story, program, advertisement, and/or image (photograph and/or videotape) made for or about Iowa Lions Eye Bank and/or University of Iowa Health Care in which I will be interviewed and quoted by name. I have been told that this story, program, advertisement, and/or image (photograph or videotape) may appear in the public media, including print, internet, and/or broadcast media for a period of up to six (6) years. I have been told that story, program, advertisement, and/or image (photograph and/or videotape) may be used by Iowa Lions Eye Bank and/or UI Health Care more than once for promotional purposes. I have been told that my health care and the payment of my health care will not be affected if I do not sign this form.
I have been informed that once information is disclosed it may no longer be protected by federal privacy regulations. I have been informed that this authorization is voluntary and that I may revoke this authorization at any time by providing notice in writing to the following address: UI Health Care Marketing and Communications, University of Iowa Health Care, 200 Hawkins Drive, W319 GH, Iowa City, IA 52242-1009. The revocation will not affect any actions taken before the receipt of this written notification. Questions? call 319-356-1009.
Iowa Lions Eye Bank and the University of Iowa Health Care will not receive, directly or indirectly, financial compensation from a third party for the use and/or disclosure of the health information described above.