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 Great Social Experiment (aka "Another Chance") to facilitate organ donation.
I understand that:
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This authorization is voluntary.
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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.
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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.
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I agree to hold The National Kidney Registry harmless from any claims or liabilities that may result from the electronic communications.
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AUTHORIZATION FOR RELEASE AND DISCLOSURE OF HEALTH INFORMATION PURSUANT TO HIPAA