I hereby authorize MedSleuth, Inc., and any related organizations (MedSleuth) the disclosure of any relevant personal health information pursuant to HIPAA to facilitate organ donation. This may include providing my personal health information to anyone who may assist me with any phase of the donation process if I opt into such communication.

The information about me may include my name, treatment modality, age, duration of treatment, treatment plan, diagnoses, videos or images of me, information about my life, and my on-going treatment.  We will not share, sell or otherwise compromise this information. For more information, please read our Terms of Use and Privacy Notice.

I understand I have the right to revoke this authorization in writing at any time. I can revoke this authorization by sending correspondence to MedSleuth, Inc.

I hereby release, discharge and agree to hold MedSleuth, Inc. harmless from any liability that may arise from the release of information authorized above.