Part I. Renal professional and caregiver certification

I hereby certify to the American Kidney Fund (AKF) as follows:

1. I am an authorized renal professional or caregiver assisting the applicant with access to the AKF Grants Management System (GMS) for purposes of creating an eligibilty profile or making a grant request.
    
2. If I am a caregiver, I attest under penalty that I have no financial incentive to assist the applicant/patient and am either a (i) family member or (ii) legal guardian with power of attorney and can present AKF with written documentation upon request. 
    
3. The confidential password I have established to access GMS shall be used by me solely and exclusively for the following purposes: (1) applying for a grant on behalf of an applicant; (2) determining the status of a grant application; and (3) determining the status of a grant (collectively, “Authorized Purposes”). I shall not disclose a GMS confidential password to any person or entity without the prior written consent of AKF.  I shall neither make nor permit any other use whatsoever of GMS data, including, but not limited to, calculating voluntary contributions to AKF for the HIPP pool. 
    
4. I will obtain a written instrument, to be signed by the applicant (patient), to (i) act as the applicant’s agent in connection with the patient eligibility profile and grant request; and (ii) authorize AKF to disclose the information provided in the application to the applicant’s (a) health care professionals and dialysis/transplant caregivers; (b) any pharmaceutical firm (if applicable); and (c) health insurance carrier for the purpose of maintaining the patient’s health insurance.
    
5. I shall retain this written authorization and provide it to AKF before any grant is issued.
    
6. I shall take all necessary and appropriate actions to protect the confidentiality of GMS data and prevent any unauthorized use of GMS data.  
    
7. I shall take all necessary and appropriate actions to maintain a virus-free computer system by keeping up to date with malware and other security protections.
    
8. I am neither an agent or representative of AKF. This means I am not authorized by AKF to act on its behalf in any capacity. I acknowledge that AKF shall not be responsible for any misuse by me of GMS data or other information I have obtained in connection with any grant application or via access to GMS.
    
9. I understand that AKF will refer to the appropriate authorities and government agencies any documents I submit to AKF for purposes of HIPP that appear to be altered in any way or where signatures are not genuine. 
    
10. I agree to hold harmless and indemnify AKF from and against all claims, liabilities, and expenses, including, but not limited to, AKF’s legal fees, that arise from or relate to any breach by me as to any of the certifications, acknowledgments and representations set forth herein. All the above certifications, acknowledgments and representations are legally binding on me. I have made them with the expectation that AKF shall rely in good faith upon them and AKF is entitled to do so.
     
11. I acknowledge that AKF, in its sole discretion, has the right to revoke at any time, with or without notice and with or without “cause,” my online privileges, including, but not limited to the right to invalidate my password.
     
12. I acknowledge that AKF may automatically will invalidate my password if my account remains inactive for greater than 90 days.
     
13. I affirm that I am at least age eighteen (18) or the age of majority in my state and will not permit access to the GMS system by anyone considered to be a minor under state law.  I understand that AKF does not knowingly collect information from an individual under the age of thirteen (13).

Part II. Patient certification

I hereby certify to the American Kidney Fund (AKF) as follows:

1. The confidential password I have established to access the on-line system shall be used by me solely and exclusively for applying for grant assistance and determining the status of my grant application. I shall not disclose a GMS confidential password to any person or entity without the prior written consent of AKF.
    
2. If I apply for grant assistance on my behalf I Authorize AKF to disclose the information provided in this application, including any protected health care information, to my (a) health care professionals and dialysis caregivers; (b) any pharmaceutical firm (if applicable); and (c) health insurance carrier for maintaining my health insurance.
    
3. I consent to have AKF and certain third parties contracted by AKF to contact me via phone (including text message where standard data rates may apply), e-mail or letter for purposes of (a) HIPP grant requests; (b) AKF related events and initiatives; and (c) kidney disease research and clinical trials.  This consent can be revoked by me at any time by contacting AKF.
    
4. If I authorize my designated Renal Professional or Caregiver to apply for grant assistance on my behalf I certify that I must provide a signed written authorization to my Renal Professional to act on my behalf as outlined in Part I (C) above.  I understand that my renal professional is required to retain this written authorization and provide it to AKF before the grant is issued.
    
5. I understand that Part I paragraphs E through J fully apply and are legally binding on me.
    
6. I acknowledge that AKF automatically will invalidate my password if my account remains inactive for greater than 360 days.
    
7. I affirm that I am at least age eighteen (18) or the age of majority in my state and will not permit access to the GMS system by anyone considered to be a minor under state law.  I understand that AKF does not knowingly collect information from an individual under the age of thirteen (13).