I, or my authorized representative, request and/or permit the disclosure, use, storage, and sharing of pertinent health information and personal information by The National Kidney Registry ("NKR") and UCHealth University of Colorado Hospital - Anschutz to facilitate organ donation and related services.

This authorization includes permission to:

• contact me directly
• provide my information to donor mentors or coaches who can help me understand the donation process if I opt into such communication
• provide my information to the transplant center(s) involved in evaluating, coordinating, facilitating, or supporting the organ donation or transplant process
• provide my information to authorized third-party service providers that support donor readiness, donor education, donor navigation, health optimization, communication, coordination, or related organ donation services

I understand that:

1. This authorization is voluntary.
2. 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.
3. Communications may be electronic, including by e-mail, text message, or other electronic methods, and such methods may not always be secure. There is no guarantee, assurance, or warranty of confidentiality for electronic communications.
4. I authorize the NKR, the transplant center(s), donor mentors, coaches, and authorized service providers to contact me using the information I provide, including by e-mail or text message.
5. I agree to hold NKR and UCHealth University of Colorado Hospital - Anschutz harmless from any claims or liabilities that may result from the electronic communications or disclosures made pursuant to this authorization.