AUTHORIZATION FOR RELEASE AND DISCLOSURE OF HEALTH INFORMATION PURSUANT TO HIPAA
I, or my authorized representative, request and/or permit the disclosure of any pertinent health information by The National Kidney Registry to facilitate kidney donation.
I understand that:
- This authorization is voluntary.
- I have the right to revoke this authorization at any time in writing,
except to the extent that action has already been taken based on this
- Communications may be electronic, such as e-mail, and such
methods may not always be secure. There is no guarantee,
assurance, or warranty of confidentiality.
- I agree to hold The National Kidney Registry harmless from any claims or
liabilities that may result from the electronic communications.
- This authorization includes disclosure of information that may relate
to alcohol use, drug use, mental health, and infectious disease information.