St. Vincent Hospital
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 and Ascension St. Vincent Hospital 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 authorization.
- 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 and Ascension St. Vincent Hospital 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.