Missouri Donor Registry - 1.1.7 2020-04-03
Organ Donor Registry Access Request
Please complete this form to request access to DHSS’ Donor Registry System.
Requested Access Role
Select Access Role
DHSS Admin Staff
OPO Call Center
SSN Last 4
By signing this Access Request Form, I certify that:
I am eligible to be an authorized user of the Donor Registry System;
I understand that Missouri law and the underlying agreement between my organization and DHSS restrict my use of Registry data to only that which is required in the performance of my assigned duties;
I will not make any inquiries or updates that are not required in the performance of my official duties, nor will I access Registry data for any unauthorized purposes;
I further understand that Missouri law and the underlying agreement between my organization and DHSS require confidentiality of Registry information;
I will keep confidential all Registry data made available to me in the performance of my official duties;
I will not divulge or share my Registry access passwords with anyone; and
I understand that if I misuse and/or disclose any Registry information, DHSS will immediately terminate my access to the Registry.