I, or my authorized representative, request and/or permit the disclosure of any pertinent health information by The National Kidney Registry and Trinity Health Grand Rapids Hospital to facilitate organ donation; this includes providing my personal information to a donor mentor who can help me understand the donation process if I opt into such communication.

I understand that:

1. This authorization is voluntary.
2. 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 authorization.
3. 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.
4. I agree to hold The National Kidney Registry and Trinity Health Grand Rapids Hospital harmless from any claims or liabilities that may result from the electronic communications.
5. AUTHORIZATION FOR RELEASE AND DISCLOSURE OF HEALTH INFORMATION PURSUANT TO HIPAA