Transfer Donor Form

1. RELEASE OF RELATED HEALTH INFORMATION FROM A HMBANA MILK BANK

Milk Donor Applicant full name*

First NameLast Name

Milk Donor Applicant birthdate*

Date

Donor number*

Child full name*

First NameLast Name

Child birthdate*

Date

Milk Donor Applicant relationship to child*

Name of HMBANA Milk Bank*

HMBANA Milk Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact at HMBANA Milk Bank name*

First NameLast Name

Contact email*

example@example.com

Contact phone number*

Please enter a valid phone number.

I authorize my HMBANA Milk Bank to release my records to the Mid-Atlantic Mothers' Milk Bank, located at 3127 Penn Avenue Pittsburgh, PA 15201, for the purpose of donating human milk to a HMBANA-accredited non-profit human milk bank. I acknowledge and consent to the release of information that may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information which could impact my milk. I am aware that I may request a copy of this documentation. I understand this authorization expires one year after the date it was executed. I understand that it may be re-disclosed by the recipient. I understand that this authorization can be revoked at any time by calling the Mid-Atlantic Mothers' Milk Bank.

Name of HMBANA Milk Bank*

Milk Donor Applicant full name*

First NameLast Name

Signature*

Please use your mouse or your finger to sign

Today's date*

Date

2. MILK DONOR APPLICANT CONSENT FORM

Please initial the following statements to acknowledge that you understand what is required of you as a milk donor. It is important for every milk donor to be knowledgeable about the milk donation process and to know exactly what is being done with their gift. If you do not understand a statement, please do not initial until all your questions have been answered by a staff member.

1. I voluntarily choose to donate my breast milk to Mid-Atlantic Mothers' Milk Bank and I understand that I will not be paid for the milk I donate. The accrediting body of nonprofit milk banks, the Human Milk Banking Association of North America (hmbana.org), strictly prohibits the payment of milk donors due to safety and ethical considerations.*

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2. I will make every effort to follow the instructions provided. I agree to notify Mid-Atlantic Mothers' Milk Bank if I take any new medications or supplements, have a change in my health, or have significantly changed my milk pumping and storage practices.*

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3. I understand that after my milk has been donated it cannot be returned to me. This is a requirement of HMBANA.*

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4. I understand that all donor information is confidential.*

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5. I understand that I can stop donating milk at any time due to my own family's needs. My child’s need for my breast milk is ALWAYS more important than providing milk for donation.*

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6. I understand that hospitals and recipients will be charged a milk processing fee to cover the costs of screening and milk processing and testing. As required by HMBANA and applicable state and federal regulations, milk donors must undergo screening and the milk itself must be tested, bottled, and pasteurized. Donor milk itself is free because it is donated. A donor milk processing fee covers the costs of blood screening, shipping, supplies, bottles, testing, staff time, etc. that are required to make donated milk safe for sick infants. HMBANA does not allow any profit to be made from donated milk. The processing fee of Mid-Atlantic Mothers’ Milk Bank is $4.50 per ounce, which is the national average among nonprofit milk banks in the United States. Hospitals order milk as a supply and pay the processing fees. Insurance often pays for medically needed outpatient donor milk. Outpatients who do not have coverage may apply to the milk bank’s charitable care program.*

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7. I agree to have my blood tested as described in Blood Testing Requirements for Donors (this is contained in the application packet) and understand that I and the health care provider of my choice will be contacted if the results are positive. Blood screening is required by HMBANA and state regulations.*

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8. I understand that my milk will be combined with other donors’ milk, which will then be drug tested and/or tested for its nutritional content. The milk of several donors is pooled together to even out natural variations and to increase the diversity of the immunological components.*

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Donor number*

9. I understand that my milk will be tested for bacteria after pasteurization(heat treatment to destroy bacteria and viruses). I understand that if the post-pasteurization bacteria test is positive, I will be contacted by a staff member to discuss how I would like to proceed (either heightened pumping hygiene practices and retesting or retiring as a donor). If bacteria are shown to be present after pasteurization, this DOES NOT indicate that your milk is unsafe for your baby. The tests performed at the milk bank are only for milk that has undergone heat treatment. Milk that shows any bacterial growth in tests performed after pasteurization cannot be distributed to hospitals or recipients. This milk may be used for required internal safety testing or quality improvement measures to support our milk bank. Some types of harmless and beneficial bacteria multiply when exposed to the heat of pasteurization rather than being destroyed. Typically, the milk bank’s positive bacterial testing rate is less than 5%. Following the pumping hygiene practices outlined in the application packet helps to keep this rate low.*

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10. I understand that being screened by Mid-Atlantic Mothers’ Milk Bank is for the intent of donating milk for use by the milk bank for distribution to hospitals and outpatients.I understand that completion of screening and approval cannot be used for any other purposes (for example, informal sharing). I also understand that Mid-Atlantic Mothers’ Milk Bank is a nonprofit organization that incurs significant costs to screen donors. Some medications, supplements, or health issues that are safe for feeding milk to a mother’s own baby may not be safe for donating milk to be used in hospitals. Donor screening is an important step in making donor milk safe for sick babies. Approval of an individual donor requires over 5 hours of staff time in addition to the cost of blood testing. Mid-Atlantic Mothers’ Milk Bank is a 501(c)(3) nonprofit organization that relies on milk processing fees, grants, and financial donations to operate.*

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11. I understand that a nominal amount of my donated milk that does not pass the screening process may be used for Mid-Atlantic Mothers’ Milk Bank’s internal testing for quality improvement measures to better nonprofit milk banking as a whole and to support the integrity of our milk bank. I understand that only milk that needs to be discarded (for example, milk that tests positive for bacteria after pasteurization) could be used for these purposes. Mid-Atlantic Mothers’ Milk Bank and all HMBANA accredited nonprofit milk banks strive to serve families in the best way possible and to maximize outcomes for medically fragile infants. It is for these reasons that nonprofit milk banks occasionally engage in quality improvement activities. As part of the screening process, donors to Mid-Atlantic Mothers' Milk Bank will be given information about its affiliated research arm, theHuman Milk Science Institute and Biobank (HMSIB). Participation in HMSIB is voluntary and separate from the milk bank.*

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I hereby certify to the best of my knowledge that I understand and have answered all questions truthfully. I have reviewed and understand the information provided to me in the application packet and during the screening interview regarding the spread of HIV and other blood borne illnesses. I do not consider myself to be a person at risk for spreading HIV or a blood borne illness.

I understand that Mid-Atlantic Mothers' Milk Bank is a part of the Human Milk Banking Association of North America (HMBANA) and may need to share medical information about donors within the association during accreditation inspections and audits. HMBANA is also bound by HIPAA and does not retain any of the information. Mid-Atlantic Mothers' Milk Bank has my permission to share needed information within my chart with HMBANA.

Milk Donor Applicant full name*

First NameLast Name

Milk Donor Applicant signature*

Please use your mouse or your finger to sign

Today's Ddate*

Date

Donor number*

3. NOTICE OF PRIVACY POLICY

To ensure your privacy, Mid-Atlantic Mothers' Milk Bank ("MAMMB") has a Privacy Policy in place as described in the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated there under, commonly known as HIPAA. HIPAA requires MAMMB, by law, to maintain the privacy of your personal health information and to provide you with notice of MAMMB's legal duties and privacy policies with respect to your personal health information. We are required by law to abide by the terms of this Privacy Notice. HIPAA requires us to:

Keep medical information that identifies you private
Give you the Notice of our legal duties and privacy practices with respect to medical information about you and your child
Follow the terms of the notice

I have read the Mid-Atlantic Mothers' Milk Bank's NOTICE OF PRIVACY POLICY (Document "D" in the screening packet) in its entirety and understand my rights under this notice.

Milk Donor Applicant full name*

First NameLast Name

Signature*

Please use your mouse or your finger to sign

Today's Ddate*

Date

Donor number*

4. HEALTH CARE PROVIDER CONTACT INFORMATION: We will be faxing your health provider.

Please provide the name and contact information of YOUR healthcare provider. We prefer this to be either your obstetrician or midwife. The physician, midwife, or nurse practitioner must be familiar with your medical history and has provided care for you during the birth of your baby.

Health Care Provider name*

Health Care Provider address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Health Care Provider phone*

Health Care Provider FAX

Please provide the name and contact information of your BABY's Healthcare Provider.

Child Healthcare Provider name*

Child Healthcare Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child Healthcare Provider phone*

Child Healthcare Provider FAX

I attest that all the above answers are true and correct to the best of my knowledge.

Signature*

Please use your mouse or your finger to sign

Today's date*

Date

Milk Donor Applicant full name*

First NameLast Name

Milk Donor Applicant birth date*

Date

Donor number*

5. MEDICAL INFORMATION REGARDING MILK DONOR APPLICANT

Milk Donor Applicant full name*

First NameLast Name

Milk Donor Applicants date of birth*

Date

Milk Donor Applicant OB Provider name*

Todays date*

Date

I authorize (OB Provider name) to release the requested medical information to Mid-Atlantic Mothers' Milk Bank. I acknowledge and consent to the release of information that may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. I am aware that I may request a copy of this document.

Milk Donor Applicant signature*

Please use your mouse or your finger to sign

Donor number*

6. MEDICAL INFORMATION REGARDING MILK DONOR APPLICANT'S CHILD

Child full name*

First NameLast Name

Child date of birth*

Date

Today's date*

Date

Child Healthcare Provider's name*

I authorize (Child Health Care Provider) to release the requested medical information to the Mid-Atlantic Mothers' Milk Bank. I am aware that I may request a copy of this document.

Milk Donor Applicant full name*

First NameLast Name

Milk Donor Applicant signature*

Please use your mouse or your finger to sign

Donor number*