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Genesis Donor Program Anatomical Gift Authorization Form

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Genesis Donor Program
Medical Education & Research Institute
Anatomical Gift Authorization Form

I, being of sound mind and body, do hereby freely make an anatomical gift of my remains upon my death to the Medical Education & Research Institute (MERI), 44 South Cleveland, Memphis, TN or its designee, for education and/or research for the advancement of medical, dental, or other health science therapy.

I understand that acceptance of this gift is contingent upon medical and suitability criteria at the time of death, and that MERI will test blood samples for certain communicable diseases, including HIV, and that positive results may be reported if required by law.

I understand that it will be the responsibility of MERI to arrange for the removal, preparation, transportation, biomedical studies on and final disposition of my remains, at no cost to me.

IT IS IMPORTANT THAT YOU AND YOUR WITNESSES SIGN ON THE SAME DAY

Donor Signature

Date

How did you hear about us?

Witness Signature

Date

Please Type or Print Witness Name

Witness Street Address

City

State

Zip

Relationship to Donor

Donor Street Address

City

State

Zip

Daytime Phone

Evening Phone

Witness Signature

Date

Please Type or Print Witness Name

Witness Street Address

City

State

Zip

Relationship to Donor

Instructions

1. This individual has made a very special and precious life-giving decision. Please notify the Medical Education & Research Institute (MERI) immediately upon death so that proper care may be provided for the donor.

2. Please note that MERI accepts no responsibility for any anatomical gift until signed and witnessed donor forms have been received.

3. In cases where an individual other than the donor is authorizing the donation, the state Uniform Anatomical Gift Act provides which individuals may make the gift, in the order specified.

4. This form bearing the original signature of the donor or authorizing party, and witnesses, must be sent or delivered to MERI, 44 South Cleveland, Memphis, TN 38104.

5. Copies of this form will be retained by MERI and should be retained by the family or official directing the donation.

6. MERI and Genesis anatomical donor program are the same institution.

7. MERI may not be able to accept every willing donor, and may decline to accept a donor who does not meet the requirements for anatomical donations at the time of the donation.

Acknowledgement or Donation by Authorizing Third-Party

I, , for humanitarian reasons, do hereby

i) make an anatomical gift of the body

ii) acknowledge the gift of the body of

to Medical Education & Research Institute (MERI), 44 South Cleveland, Memphis, TN, or its designee, for education and research for the advancement of medical, dental, or other health science field or therapy.

My relationship to the donor is .

By checking this box, I request that the MERI contact me concerning any positive serological results, so that I may authorize the release of such information, and other personal medical information, to the extent permitted by law.

Signature of Authorizing Party

Date

Relationship to Donor

Authorizing Party Information

Street Address

City

State

Zip

Please Print or Type the Name of the Authorizing Party

Daytime Phone Number w/area code

Evening Phone Number w/area code

How did you hear about us?

Donor Vital Statistics Information

Full Legal Name

First

Middle

Maiden

Last

SSN

Sex

Date of Birth

Donor’s Age

Donor’s Permanent Address

Street

City

State

Zip

County

Within city limits? Number of years you have resided at this residence?

Donor’s Home Phone w/area code

Place of Birth

City

State

County

Are you a U.S. Citizen?

Have you ever served in the armed forces? Yes No If yes, what branch?

Marital Status

Name of surviving spouse

Occupation

Employer

Race

If of Hispanic origin, please specify

Elementary/Secondary (0-12) College (1-4 or 5+)

Donor’s Father’s Name

First

Middle

Last

Donor’s Mother’s Name

First

Middle

MAIDEN

Name and current address of Donor’s Authorizing Party or Next-of-Kin

Relationship to Donor

Street Address

City

State

Zip

Daytime Phone w/area code

Evening Phone w/area code

Should donor’s ashes be returned to family or other individual(s)? Yes No

Name of person to receive the ashes

Relationship to Donor

Street Address/City/State/Zip

Daytime Phone w/area code

Evening Phone w/area code

Suspected Cause of Death

Donor’s Date of Death

Donor’s Age at time of Death

Place of Death

County of place of Death

Medical History Form

I, do hereby give my written permission to release my/the donor’s medical records on file at the time of death to the Medical Education & Research Institute (MERI), 44 South Cleveland, Memphis, TN.

Past Surgeries / Illnesses

Current Medication(s)

Have you ever had a hepatitis vaccine?

Blood transfusion?

Height? Weight?

Do you smoke? If yes, how long?

Quit? When?

Do you drink alcohol? If yes, how long?

Quit? When?

Please provide the name(s), address(es) and phone number(s) of any physician(s) who can provide information about your medical history:

Donor / Authorizing Party Signature

Donor / Authorizing Party Address

Special Projects Gift Consent

Anatomic gifts to the MERI are used for the advancement of clinical research and hands on medical training. Participation in special projects is voluntary and requires separate authorization.

Your signature below authorizes the use of donor’s body in a Special Project, including but not limited to the project described above.

Donor or Authorizing Party Signature

Date

Please print or type the name of Authorizing Party

Frequently Asked Questions

1. Can a person be an organ donor and a Genesis Donor? Yes, you can sign the back of your driver’s license or any other Advance Directive document to be an organ donor and complete our forms to be a Genesis donor as well.

2. How soon after death should the MERI be contacted? Immediately. It is imperative that MERI be notified as soon as possible so that proper care may be given to your loved one.

3. Who is responsible for transporting the Donor to the MERI? Upon notification of your loved one’s death, arrangements will be made by MERI for transportation and care.

4. How and when will I receive the death certificates? The MERI will file and pay for up to 6 death certificates and forward them as soon as received.

5. What happens when the studies on the Donor have been completed? A donor’s completion usually takes six months to one year. The donor is then cremated at no cost to the family.

6. Is it possible to have the Donor’s ashes returned to the family? Yes, at the time of death the family should request this.

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What the Genesis Donor Program Anatomical Gift Authorization Form Is

The Genesis Donor Program Anatomical Gift Authorization Form is a legal consent document used to authorize donation of organs, tissues, or anatomical gifts for transplantation, research, or education. It records the donor's intent, specifies which parts may be used, and documents any limitations or purposes the donor chooses. The form is designed to be completed by the donor or an authorized representative and retained by medical providers and the donor registry. It may be executed on paper or electronically where allowed under federal and state e-signature laws such as ESIGN and applicable state statutes.

Why this Authorization Form Matters

This form provides a clear, legally recognized expression of the donor's wishes, reduces uncertainty for families and clinicians, and helps ensure organs or tissues are handled according to the donor's instructions and applicable law.

Why this Authorization Form Matters

Who Completes and Relies on This Form

Typical filers and users include individuals wishing to donate, their legal representatives, and clinical staff coordinating donation.

  • Donors and prospective donors who want to document specific anatomical gift instructions for transplantation, research, or education.
  • Hospital transplant coordinators and organ procurement organizations that need a recorded legal authorization to proceed with donation.
  • Family members and legal representatives who may need to confirm or present the donor's recorded authorization at the time of death.

Clear completion and timely delivery to the registry or clinical team helps avoid disputes and speeds donor acceptance.

Who Can Sign and When

Donor — Individual

A mentally competent adult donor may sign to authorize anatomical gifts. If signed by the donor, the form is the primary evidence of the donor's intent and generally controls absent clear evidence to the contrary.

Authorized Representative

If the donor lacks capacity, a legally appointed agent, guardian, or an individual with authority under state law may sign consistent with local statutes; state rules differ on who may act posthumously.

Essential Components of a Complete Authorization

A professional Genesis Donor Program Anatomical Gift Authorization Form contains a consistent structure to capture identity, scope, timing, and authentication details required for legal and clinical use.

Donor Identification

Full legal name, date of birth, and a secondary identifier (medical record number, driver's license number, or last four of SSN) ensure the authorization matches patient records when donation is considered.

Authorization Statement

A clear clause stating the donor's intent to donate specified anatomical parts for transplantation, research, or education with any limitations or exceptions explicitly listed.

Scope and Purpose

Precise language identifying permitted uses (e.g., transplant only, transplant and research, anatomical study) prevents misinterpretation at the time of procurement.

Effective Date

A date field or event trigger (for example, effective upon death) confirms when the authorization becomes operative and affects procurement timing and disposition decisions.

Signature and Authentication

Signature line, printed name, date, and any witness or notarization block required by state law or facility policy provide legal validation of the donor's consent.

Record Distribution

Fields for indicating where copies are sent—medical record, organ procurement organization, and donor registry—improve coordination during clinical handoff.

Privacy, Security, and Compliance Essentials

Protected Health Information: Treat as PHI under HIPAA.
HIPAA BAA: Business associate agreement required.
Audit Trail: Capture signer identity and timestamps.
Encryption: Use TLS in transit, AES-256 at rest.
Access Controls: Role-based access to signed records.
Retention Policy: Store per legal and clinical retention rules.

Step-by-Step: Completing the Authorization

A concise sequence to prepare, complete, and distribute the completed authorization so it is available when clinically needed.

  • 01
    Prepare Documents: Gather ID and medical record details.
  • 02
    Fill Form: Complete all required fields clearly.
  • 03
    Authenticate: Sign and obtain required witness or notary.
  • 04
    Distribute: Send copies to registry and clinical team.

Configuring an Online Completion Workflow

Key settings to configure when using an electronic form platform to collect anatomical gift authorizations.

Field Configuration
Authentication Email + SMS code recommended
Notifications Auto-email copies to OPO and EHR inbox
Template Reuse Enable version control and templates
Audit Retention Retain signed audit trail indefinitely

Digital Signing and System Requirements

Electronic collection requires secure storage, appropriate signer authentication, and export formats compatible with clinical systems.

  • File Formats: PDF and DOCX supported
  • Integrations: EHR, OPO, registry integrations
  • Browser Support: Modern browsers and mobile apps

Ensure the chosen platform supports HIPAA (BAA available), produces an auditable certificate of completion, and exports signed records in PDF/A or standard PDF for EHR ingestion.

Where Completed Authorizations Should Go

Typical routing ensures the authorization is available to clinicians, organ procurement teams, and registries when needed.

  • Hospital Medical Record: Upload to the patient's EHR immediately
  • Organ Procurement Organization: Send copy to the OPO handling the case
  • State Donor Registry: Register entry where available
  • Family/Representative: Provide a signed copy to next of kin

Timing and When the Authorization Takes Effect

Understand effective dates and immediate steps at the time donation becomes possible to prevent delays in procurement.

Effective Upon Signature:

Most authorizations are effective when signed by the donor

At Time of Death:

Some forms specify they are operative only upon donor's death

Hospital Notification:

Deliver to clinical team as soon as donation is considered

Registry Entry:

Register immediately to reflect donor status

Revocation Timing:

Revocation is effective when properly delivered to holders

Common Errors to Avoid

  • Incomplete donor identifiers that do not match medical records cause verification delays and potential declination of donation.
  • Inconsistent or abbreviated names (initials, nicknames) that differ from government ID impede matching during organ acceptance.
  • Missing witness or notarization when required by state law or facility policy can render the form unusable for procurement.
  • Failing to deliver copies to the hospital, OPO, or registry in advance increases the risk of logistical delay at time of death.

Risks and Legal Consequences of an Incorrect Form

Invalid Consent: Procurement may be prohibited
Delayed Donation: Time-sensitive organs may be lost
HIPAA Violation: Possible civil penalties
Estate Disputes: Family litigation risk
Regulatory Noncompliance: Facility policy violations
Operational Burden: Increased coordination and cost

Comparing eSignature Providers for This Authorization Form

High-level pricing and feature comparison for eSignature platforms; signNow is presented first for parity in vendor comparison tables.

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 free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Practical Tips for Smooth Completion and Acceptance

Apply these best practices to minimize delays and ensure the donor's intent is honored when donation is possible.

Match Government ID
Always enter the donor's legal name and date of birth exactly as shown on government-issued identification to speed verification and reduce the risk of declined procurement or registry mismatch.
Be Specific About Scope
Specify permitted uses and any exclusions clearly (for example, list organs to exclude) to prevent later disputes and to align clinical planning with donor wishes.
Distribute Copies Early
Provide signed copies to the hospital medical record, the organ procurement organization, and the donor registry in advance; prepositioned authorizations reduce delays at time of death.
Confirm Authentication
If electronic signing is used, ensure authentication level and retention meet facility policy and any applicable state or federal requirements, including HIPAA protections.

Real-World Scenarios

Examples illustrate common uses and practical outcomes when the form is completed and routed correctly.

Hospital Coordination

A donor records consent online linked to the EHR

  • OPO is notified immediately
  • As a result, procurement proceeds without family dispute and transplant teams accept organs on time due to verified authorization and audit trail.

Legal Integration

An estate attorney includes the authorization with an advance directive

  • Witnessing and notarization are completed per state rule
  • The combined documents prevent confusion during probate and support timely donation.

Frequently Asked Questions and Troubleshooting

Answers to common questions about validity, e-signing, witnesses, revocation, and record handling for anatomical gift authorizations.


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