Healthcare Renewal Donation Form

HEALTHCARE RENEWAL DONATION FORM

Purpose: Use this form to renew an existing charitable donation commitment to the healthcare organization and to authorize recurring charges where elected. Completion of this form constitutes a binding authorization to process donations as described herein and confirms the donor's representation that the information provided is accurate. Please print clearly.

Donor / Patient Information

Emergency Contact

Insurance Information (Optional)

Medical History (for patient records)

Donation Renewal Details & Authorization

I hereby renew my charitable donation to the healthcare organization in the amount of $ per Frequency: Monthly Quarterly Annually One-time beginning on .

Payment Method (select one or more; additional details required below):

Legal Authorization and Acknowledgments

Authorization: By signing below I authorize the healthcare organization to charge the payment method indicated above for the amount and frequency specified. This authorization shall remain in effect until the organization receives written notice of cancellation at least 15 days prior to the next scheduled donation. I understand that I may revoke this authorization at any time by submitting written notice to the organization and that such revocation will not affect charges already processed in reliance upon this authorization.

Representations: I represent that I am an authorized signer on the account or card provided and that all information provided on this form is true and correct. I agree to notify the organization promptly of any changes to payment information. I further authorize the healthcare organization and its agents to contact me by telephone, text, and email regarding donation processing.

Tax Acknowledgment: The organization will provide appropriate tax receipts where required. I acknowledge that no goods or substantial services were provided to me in consideration for this donation unless specifically stated by the organization. If any benefit is provided, I understand that its fair-market value will be disclosed on my receipt.

Limitation of Liability: To the extent permitted by law, the donor releases and holds harmless the organization from liability for any loss or claim arising from the use of the information supplied on this form, except for losses arising from the organization's gross negligence or willful misconduct.

Authorization Expiration: This authorization will expire on unless the donor elects the following option: Continue until revoked in writing.

Privacy, HIPAA & Communications

Privacy: I understand that the organization may use information provided on this form to process donations, to issue receipts, and for necessary donor stewardship and compliance. The organization will maintain donor information in accordance with its privacy practices and applicable law. By signing, I consent to the use of my contact information for donation-related communications.

Cancellation & Refund Policy

Cancellation: To cancel or modify a renewal donation, donors must provide written notice to the organization. Refunds, if any, will be processed in accordance with the organization's refund procedures. The organization reserves the right to suspend or cancel donation processing if payment cannot be completed or upon discovery of inaccurate or fraudulent payment information.

Certification: By signing above I certify under penalty of law that I am authorized to execute this donation authorization and that the information provided on this form is true and complete to the best of my knowledge.

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