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 Montefiore Medical Center to facilitate organ donation.

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 Montefiore Medical Center harmless from any claims or liabilities that may result from the electronic communications.
5. This authorization includes disclosure of information that may relate to alcohol use, drug use, mental health, and infectious disease information.