Consent-

DONOR CONSENT PRIVACY AND CONFIDENTIALITY FORM

1. I voluntarily choose to donate my breast milk to Mothers' Milk Bank California, understanding that I will not be compensated and that my milk will not be sold. A processing fee may be charged to the recipient. My milk or data may be used for research purposes.
2. I will ensure my donations follow the provided guidelines and will notify Mothers' Milk Bank California if:
   a. I, my baby, or anyone in my household becomes ill.
   b. I take any prescribed or over-the-counter medications, supplements, or herbal products
   c. Family obligations prevent me from donating.
   d. I have questions or concerns about being a donor.
   e. I am exposed to a contagious illness.
3. I understand that once donated, my milk becomes the property of Mothers' Milk Bank California and cannot be returned.
4. I authorize the laboratory or my healthcare provider to send test results to Mothers' Milk Bank California via confidential email or regular mail.
5. I understand a sample of my milk will be tested for bacteria before and after pasteurization.
6. I have reviewed information about HIV and blood tests for donors, and I do not consider myself at risk for infectious diseases.
7. I agree to have my blood tested as described in Blood Test for Milk Donors. I understand I will be notified of any abnormal results.
8. I understand I can discontinue donating milk  at any time if it interferes with my family's needs.
9. I have read and understood all the donor information presented to me and had my questions answered. I certify that I have answered all questions truthfully.
10. I understand that acceptance by Mothers' Milk Bank California as a donor is in no way an indication that my milk is safe to share with individuals outside the milk bank process. Milk banks take several steps to assure the safety of donor milk beyond health screening of the donor. Therefore, it is a misrepresentation to use the Milk Bank screening process to guarantee the safety of my milk for a recipient if it has not gone through processes similar to those used by a donor milk bank.
11. I understand that all donor information is confidential and protected health information may be used and disclosed to your primary health care provider if information discovered in the screening process needs further evaluation or treatment. I acknowledge I've been given the opportunity to read and review the Department of Health and Human Services Security and Privacy Administrative Standards in the Federal Register CFR Part 164.506. Mothers' Milk Bank California follows in accordance to HIPAA and I understand I have a right to review this before signing below.
12. I understand I have the right to request how my information is used, but the bank may decline such requests. I have the right to revoke this consent in writing, though public health concerns may necessitate disclosure.

Please sign form below if you would like to share your story.

(Optional) Designated Party Authorization for Release of Medical Information

Some patients prefer that other individuals especially family members, be allowed access to their medical information. In order to comply with strict legal standards, a written release is required to allow another person access to your medical records.

This release grants permission to individual(s) listed below to: make or confirm appointments, have access to my medical charts and laboratory findings, and serve as my emergency contact. This permission applies to telephone and answering machine messages as well as other means of communication and will be in effect unless I notify this office of any change or revocations.

1887 Monterey Rd, Suite 110 San Jose, CA 95112 408-998-4550 FAX 408-297-9208
www.camilkbank.org
Member of the Human Milk Bank Association of North America
Non-profit #77-0131926