Montana and Washington Donor Document of Gift
The individual named below is listed in the Donor Registry created by Montana statute and
Washington statute. This is an authorization for anatomical gifts to be made upon death. A
signature of the deceased is not required but will be provided when available.
I consent to the donation and removal of organs/eyes/tissues, from my body by surgeons
and technicians authorized by procurement programs serving Washington and Montana. I
understand this consent authorizes tests, examinations, or procedures that are necessary to
assure medical acceptability of all organs/eyes/tissues and to assist in matching organs/eyes/tissues
with appropriate recipients in accordance with current medical standards. This includes, but is not limited
to, testing for HIV and other transmissible diseases. I also understand these test results may be the basis
for not using organs/eyes/tissues for transplantation.
I consent to the release of my complete medical record, as necessary, to those individuals involved
in the organ/eye/tissue donation, recovery and transplantation process. I understand that this release
of information includes medical records, autopsy reports, serological test results (including, but not
limited to HIV) of infectious diseases, and documentation of mental health or substance abuse treatment.
I expressly agree that the above stated recovery agencies may disclose such information as it deems necessary.
I understand that all hospital and medical expenses incurred prior to signing this consent or which are
unrelated to organ/eye/tissue donation will be the responsibility of my financial provider. I further understand
that there will be no charge for hospital or medical services relating to the organ/eye/tissue donation from the
time of brain death, or cardiac death diagnosis, or when the procurement organization(s) has accepted
financial responsibility through the recovery of the organs/eyes/tissues.
I have been told, understand and agree that unless otherwise specified below, these donations
are made without limitation to Washington and Montana procurement organizations or their designee,
and may be used for any lawful purpose including transplantation, therapy, specialized transplant needs,
and/or the production of health-related products by an appropriate entity. If I am under the age of 18,
I understand that consent must be obtained from my parents or legal guardian at the time of donation,
unless I am legally emancipated.
Terms & Conditions
Under Montana and Washington Revised Statute, an anatomical gift not revoked by the donor before
death is irrevocable and does not require consent or concurrence of any person after the donor's death.
The donation programs in accordance with accepted medical and ethical standards will coordinate the
recovery and allocation of these gifts. For more information about the Donor Registry please call
1.877.275.5269 or log onto donatelifetoday.com.