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California Uniform Anatomical Gift Act Donor Network

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REVOCATION OF ANATOMICAL GIFT

I, Declarant, having made an anatomical gift by virtue of

that document of gift dated the day of , 20

do hereby revoke such gift pursuant Florida Statutes §765.516 which provides that an anatomical gift may be revoked as follows:

(a) The execution and delivery to the donee of a signed statement witnessed by at least two adults, at least one of whom is a disinterested witness.

(b) An oral statement that is made in the presence of two persons, one of whom is not a family member, and communicated to the donor's family or attorney or to the donee. An oral statement is effective only if the procurement organization, transplant hospital, or physician or technician has actual notice of the oral amendment or revocation before an incision is made to the decedent's body or an invasive procedure to prepare the recipient has begun.

(c) A statement made during a terminal illness or injury addressed to an attending physician, who must communicate the revocation of the gift to the procurement organization.

(d) A signed document found on or about the donor's person.

(e) Removing his or her name from the donor registry.

(f) A later-executed document of gift which amends or revokes a previous anatomical gift or portion of an anatomical gift, either expressly or by inconsistency.

(g) By the destruction or cancellation of the document of gift or the destruction or cancellation of that portion of the document of gift used to make the gift with the intent to revoke the gift.

(2) Any anatomical gift made by a will may also be amended or revoked in the manner provided for the amendment or revocation of wills or as provided in paragraph (1)(a).

This is my written revocation of my anatomical gift and is provided to all persons to whom I have provided a copy of my document of anatomical gift.

DATED this the day of , 20

Name of Declarant

Printed Name of Declarant:

Address of Declarant:

Witness

Print Name:

Witness

Print Name:

Enter text✕
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What the California Uniform Anatomical Gift Act Donor Network Is

The California Uniform Anatomical Gift Act Donor Network is a standardized donor designation and organ procurement coordination form used in California to document an individual's anatomical gift preferences and to register those preferences with an authorized donor network. It records donor identification, the extent of donation consent (organs, tissues, or whole body), any limitations, and designated agents or next of kin. The form helps medical providers, organ procurement organizations, and legal representatives locate and verify donor intent in time-sensitive circumstances while aligning with California statutory expectations for anatomical gifts.

Why this donor network form matters

Use the California Uniform Anatomical Gift Act Donor Network to make legally recognized donation choices, clarify scope of consent, and speed organ procurement decisions. The form reduces uncertainty for providers and supports compliance with California anatomical gift statutes.

Why this donor network form matters

Core sections and practical features of the form

Core sections and features of the California Uniform Anatomical Gift Act Donor Network determine legal effect, express consent, and practical routing for procurement and registry processing.

Donor Identification

Includes full legal name, date of birth, government ID number, and contact information. Accurate identification supports registry matching, reduces disputes, and is required by procurement organizations during verification.

Consent Scope

Specifies organs, tissues, or whole-body donation choices and any limitations. Clear scope prevents retrieval beyond donor intent and informs clinical teams and allocation decisions.

Designation

Optional section to name an agent or representative authorized to make or confirm anatomical gift decisions. Include contact details and legal relationship to donor.

Medical Information

Basic medical and allergy information that may affect suitability for donation; provides context for procurement but does not replace full medical screening.

Signature Block

Signed and dated acceptance by donor or authorized representative. May include witness or notary lines depending on state rules or institutional policies.

Registry Routing

Instructions and identifiers for submission to California donor networks and organ procurement organizations, plus fields for internal audit and processing timestamps.

Step-by-step completion and submission process

Follow these sequential steps to complete, verify, and submit the donor network form so clinical teams and organ procurement organizations can act without delay.

  • 01
    Confirm Identity: Match legal name and government ID.
  • 02
    Select Scope: Choose organs, tissues, or whole-body specifically.
  • 03
    Designate Agent: Provide name, relation, and contact details.
  • 04
    Sign & File: Sign in required format and submit to registry.

How the completed form is routed and used

Overview of routing, verification, and how donor network data is used by hospitals and organ procurement organizations to support timely retrieval decisions.

  • Upload Record: Attach completed form to donor registry and EHR.
  • Verify Identity: Registry confirms matching government identifiers and birthdate.
  • Notify OPO: Organ procurement organization receives notification for eligible donors.
  • Access During Care: Clinical teams retrieve registered preferences rapidly during critical events.

Digital workflow settings for e-submission and routing

Digital workflow settings for e-submission, verification, and routing to California donor networks and organ procurement organizations.

Field Configuration
Authentication SMS code plus email link verification
File Format PDF/A or signed PDF accepted
Routing Auto-route to OPO and registry
Archive Retain signed copy in secure storage

Platform and technical requirements for secure e-submission

Technical and integration requirements to e-submit the donor network form and maintain audit-ready records securely.

  • Formats Supported: PDF, DOCX, HTML accepted
  • Integrations: EHRs, Salesforce, NetSuite, Google Workspace
  • Security: TLS 1.2/1.3 and AES-256 encryption

Security and compliance features to look for

Encryption in Transit: TLS 1.2 and TLS 1.3 protocols
Encryption at Rest: AES-256 bit encryption for stored records
Audit Trail: Timestamped events, IP addresses, action logs
HIPAA Compliance: BAA required when PHI is stored or transmitted
Access Controls: Role-based access and multi-factor authentication
Certifications: SOC 2 Type II, ISO 27001, PCI DSS

Comparing eSignature providers for donor network workflows

Neutral comparison of baseline pricing and feature availability for common eSignature providers; signNow is listed first per vendor order rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes Yes
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Key roles involved in completion and verification

Transplant Coordinator

Transplant coordinators complete registrations, verify donor identification, record consent scope, and communicate with procurement organizations and transplant teams. Their entries are relied upon during time-critical decision-making; errors or omissions can delay retrieval and affect organ allocation timelines.

Donor or Representative

Donors or their legally authorized representatives provide instructions, list limitations, and may designate agents. Clear, consistent information and matching government identification reduce disputes and support legal enforceability under California anatomical gift statutes.

Who typically fills out and relies on this form

Healthcare providers, organ procurement organizations, donor network coordinators, and individuals completing donor registrations commonly use this form.

  • Organ procurement organizations coordinating retrievals, allocation determinations, and communication with transplant centers
  • Hospital transplant coordinators verifying donor intent during clinical assessment and end-of-life care
  • Individuals or legally authorized representatives registering anatomical gift preferences and listing permitted limitations

Real-world examples of improved consent capture

Two practical examples showing how standardized donor network records reduced friction and improved verification in clinical operations.

Optica Ventures — Brian Fitzgibbons

Optica Ventures used the donor network form to centralize donor registrations and speed cross-organization verification for time-critical cases.

  • Simplified intake and verification across teams.
  • Brian Fitzgibbons observed that a simpler interface made it easier for staff and external partners to complete forms accurately, reducing follow-up calls and helping procurement teams access verified donor intent faster during critical clinical windows.

Fertility Centers of Illinois — John Butler

The fertility center adopted the form to document tissue donation authorizations alongside patient records.

  • Reduced administrative friction in consent capture.
  • John Butler praised responsive support and API integrations that allowed completed donor records to attach to patient files, improving traceability and alignment with institutional retention policies for medical records.

Best practices to avoid delays and disputes

Practical tips to reduce errors and speed processing when completing the donor network form in clinical or registry contexts.

Verify government ID against form
Before submission, compare the donor's government-issued identification to the name and birthdate on the form. Discrepancies should be reconciled immediately; mismatches commonly cause registry rejections and delay procurement decisions.
Use explicit organ/tissue terminology
List each organ or tissue you authorize by name. Avoid vague phrases such as 'some tissues' or 'as needed' — specificity reduces legal ambiguity and speeds clinical suitability assessments.
Retain signed copies securely
Store signed originals in the patient's medical record and retain an encrypted digital archive with access logs. Verify retention meets HIPAA (45 CFR §164.530(j)) and institutional records schedules to support audits.
Document eSignature details and consent
When using e-signatures, record the authentication method, timestamp, and signer attribution. Maintain any consumer disclosures required by ESIGN (15 U.S.C. ch. 96) to preserve legal enforceability.

Common pitfalls to avoid when preparing the form

  • Failing to match government-issued ID details, causing registries to reject or fail to locate the donor record during urgent procurement windows
  • Using vague language for scope of donation instead of listing specific organs or tissues permitted for donation, creating uncertainty for clinical teams
  • Omitting a designated agent or emergency contact, which can make decision confirmation slower when next of kin are unavailable
  • Submitting unsigned or partially completed forms, or relying on illegible scans that procurement teams cannot authenticate quickly

Risks and potential consequences of errors

Incorrect Identification: May prevent verification and delay donation
Ambiguous Consent: Limits or invalidates retrieval authority
Missing Signature: Could render form unenforceable
Improper Witnessing: State rules may require witness or notary
HIPAA Violations: Improper PHI handling can trigger penalties
Timing Issues: Delayed filing can obstruct procurement

Timing and deadlines to keep in mind

Key timing considerations for completing and making donor preferences available to clinical teams and organ procurement organizations.

Immediate Availability:

Make form available to clinical staff as soon as completed

Registry Update:

Submit to state registry promptly; delays may impede retrieval

End-of-Life Context:

Ensure form is present in medical chart during terminal events

Notarization Window:

If notarization is required, complete before legal incapacity occurs

Document Retention Start:

Retention begins on execution date; follow retention timeline

Frequently asked questions and practical answers

Answers to common questions about completing, signing, submitting, and revoking entries in the California Uniform Anatomical Gift Act Donor Network form.


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