Informed Consent for Birth Tissue Donation

Birth Mother Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Phone type*
Mobile, home, work, etc.
Email*
example@example.com
Person completing this authorization form:*

Mother/Birthing parentLegal Representative or Other Authorizing Person

Legal Representative or Other Authoring Person's Name:*

First NameLast Name
Relationship:*
How are you connected to the mother/birthing parent?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Authorization

Initial each statement below.
1. I authorize access to and release of medical records of the birth mother and infant, including prenatal records and hospital records, or other information pertinent to the screening, acquisition, evaluation or follow-up of the anatomical gift to Gift of Life Michigan and their contracted partners. I authorize a blood sample to be drawn for Gift of Life Michigan for the purpose of screening for hepatitis, sexually transmitted infections and other infectious diseases, including the virus that causes HIV/AIDS.*
Initial above
2. I authorize the release of these test results to any organization or individual involved in the screening, acquisition, evaluation or follow up of donated tissues. Except for the limited disclosure of test results as required by law and the disclosure to health care personnel, the results of these tests will remain confidential.*
Initial above
3. All information collected by Gift of Life Michigan will be protected as governed by the US Health Insurance Portability and Accountability Act (HIPAA) and anonymity and confidentiality will be maintained at all times by Gift of Life Michigan and its associates. Donation records, including authorizing party information will be maintained securely at Gift of Life Michigan as required by law. *** U.S. should have periods, as it does in question 6. Is it okay to correct it? ****
Initial above
4. I authorize a Gift of Life Michigan team member to be present during the procedure to facilitate the acquisition and preservation of any donated tissues. I understand that the decision to donate does not create any additional risk to the birth mother, baby, or legal representative. The physician or designee has not been asked to change their procedure for the purpose of donation and the procedure is the sole responsibility of the physician or designee.*
Initial above
5. I understand that this gift is being made voluntarily without any monetary compensation or other valuable consideration, nor will a fee be charged for any aspect of donation. Expenses not related to the donation will remain the responsibility of the birth mother or legal representative.*
Initial above
6. I understand that multiple organizations, not-for-profit and/or for-profit in the U.S. and/or internationally may be involved in the facilitation, preparation, testing and distribution of tissue grafts.*
Initial above

7. I release Gift of Life Michigan, their respective employees and associates, as well as any hospital or other organization and its employees from any liability that may otherwise result from performing the necessary procedures to carry out this gift, so long as they have acted in good faith.*
Initial above
8. I agree to complete the Birth Tissue Donation Risk Assessment Interview truthfully to the best of my knowledge to ensure the suitability of the birth tissue for transplant may be properly determined.*
Initial above
9. I acknowledge that I am not under the influence of any substance that could impact my ability to give consent. I acknowledge being given the opportunity to ask questions about this donation, and all information was provided actively without coercion. There is no guarantee that donation will take place, and I have the ability to revoke this consent at any time prior to donation.*
Initial above
Questions?

Copies of completed documents will be provided to all applicable parties. For more information, including available support services, questions or comments, please contact Gift of Life Michigan's customer service line (866) 500-5801, ext. 1411 or visit giftoflifemichigan.org. *** I'd like to incorporate this part into the webpage itself, rather than at the bottom of the form. Question 9 has them agreeing that they've had the opportunity to ask questions but we have not actually shown them where/how to do that until after we ask them to agree. ****
Signature

This authorization is a binding, legal document of your generous gift. You affirm the information provided is accurate.
Signature*

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