Healthcare Donor Information Form

HEALTHCARE DONOR INFORMATION FORM

Donor Identification

Donor Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Donation Details

Type of Donation (check all that apply):

Whole blood
Platelets
Plasma
Tissue
Organ
Biological sample for research
Monetary/gift donation

Medical History & Screening

Complete medical history information is required to determine eligibility for donation and to ensure recipient safety. Provide full responses below.

Infectious Disease History (check all that apply):

HIV/AIDS
Hepatitis B
Hepatitis C
Tuberculosis
None of the above
Other:

Testing, Consent, Risks & Benefits

I understand that standard testing of donated material may include infectious disease screening, compatibility testing, and other laboratory analyses necessary to protect recipients and public health. I consent to such testing and to the collection of samples required for testing and recordkeeping.

I acknowledge that donation may involve risks including, but not limited to, localized pain, bleeding, infection at collection site, transient weakness, and other conditions specific to the type of donation. Benefits may include potential therapeutic benefit to recipients and contribution to medical research and education. I understand I may withdraw my consent prior to the collection process; withdrawal after collection may be limited by clinical, safety, or legal constraints.

I consent to required testing and specimen collection as described above.

Privacy, HIPAA Acknowledgment & Release

I acknowledge that the medical information I provide is protected health information. By signing below I authorize the release and use of my protected health information as necessary to facilitate donation, testing, treatment, billing, transplantation, and reporting to public health authorities where required by law. This authorization includes disclosure to clinicians, laboratory personnel, recipient centers, and entities overseeing transplantation and tissue safety.

I understand that my information will be handled in accordance with applicable privacy laws and that I may request restrictions in writing; however, such restrictions may be limited when needed to ensure recipient safety or fulfill legal obligations.

I acknowledge receipt of the privacy notice and authorize use/disclosure of my health information as described above.

Authorization to Release Medical Records

I authorize any healthcare provider or facility to release my medical records and test results necessary for evaluation of my eligibility to donate and for management of donated material. This authorization permits release for the purposes of donor screening, recipient safety, quality assurance, and regulatory compliance.

I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of revocation.

Certification

I certify under penalty of law that the information I have provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information may disqualify me from donation and may subject me to civil or criminal penalties where applicable.

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