Healthcare Donor Agreement

HEALTHCARE DONOR AGREEMENT

Donor Name:   Date of Birth:

Receiving Institution Name:

1. Donor Information

2. Insurance Information

3. Medical History (Relevant to Donation)

I certify that the medical history information provided above is true and complete to the best of my knowledge. I certify

4. Donation Details and Intended Use

Type of Donation (check all that apply):
Organ for transplantation    Tissue for transplantation    Blood / blood products    Biospecimens for research/education    Other:

Intended Use (check all that apply):
Transplantation    Research    Education / training    Quality assurance / improvement    Commercial development (I understand I will not receive compensation)

5. Risks, Benefits and Alternatives

I have been informed of the potential risks, discomforts, and benefits associated with the donation described above. I understand that risks vary depending on the type of donation and may include infection, bleeding, pain, procedural complications, and the potential that tissue or specimens may not be suitable for the intended purpose. Alternatives, including declining to donate, have been explained to me.

Acknowledgement: I acknowledge that these risks, benefits, and alternatives were explained to me and I had the opportunity to ask questions.

6. HIPAA Authorization and Use of Protected Health Information

I authorize the Receiving Institution, and its affiliates, to use and disclose my protected health information (PHI) reasonably necessary to accomplish the purposes of this donation, including but not limited to: medical records related to the donation, laboratory results, imaging, operative and pathology reports, and demographic information. PHI may be disclosed to transplantation organizations, research entities, educational institutions, and other third parties involved in the handling, testing, storage, or use of donated material.

Scope of Authorization: All PHI described above    Only PHI limited to donation-related records

I understand that my authorization will expire on the date specified above, unless revoked earlier in writing as provided below. If no date is provided, this authorization will remain effective until the Receiving Institution completes processing and disposition of the donated material consistent with this Agreement.

7. Revocation and Withdrawal

I understand that I may revoke this Authorization at any time by delivering a written, signed, and dated revocation to the Receiving Institution. Revocation will be effective upon receipt by the Receiving Institution, except to the extent that action has already been taken in reliance upon this Authorization. I understand that revocation may not be possible for donations that have already been processed, used, or distributed.

8. Ownership, Transfer, and Commercial Use

I understand and agree that, upon collection, donated material may be owned or controlled by the Receiving Institution or by third parties to whom the material is lawfully transferred. Such material may be used for the purposes described above, and may be modified, stored, de-identified, banked, or combined with other materials. I understand that donated material may result in discoveries or products that could be commercialized, and I will not receive financial benefits from commercialization.

9. Compensation and Costs

I understand that I will not receive compensation for the donation. The Receiving Institution will disclose any reasonable costs or charges associated with the collection or processing of the donation prior to collection if applicable.

10. Liability, Indemnification and Certification

To the maximum extent permitted by law, the Receiving Institution and its employees, agents, and contractors shall not be liable for unanticipated outcomes directly related to donation, except in cases of willful misconduct or gross negligence. I agree to release and hold harmless the Receiving Institution from claims arising from the donation and use of the donated material consistent with this Agreement.

Certification: By signing below I certify that I am the named donor or am legally authorized to act on behalf of the donor, that I have read and understand this Agreement, that I have had an opportunity to ask questions and receive answers, and that I voluntarily consent to the donation and uses described herein.

11. Additional Authorizations and Preferences

Contact Preferences:
I authorize being contacted for important research findings or follow-up related to materials donated.    I do not wish to be contacted regarding future research or results.

A copy of this signed Healthcare Donor Agreement shall be provided to the Donor or the Donor's legally authorized representative upon request as a record of consent and authorization.

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