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  1. 1. Adoption NLC P/P #6600.0105
  2. 2. Policy:• The primary nurse of a birth mother expressing an interest in having her child placed for adoption will make a referral to White County Medical Center Social Work Services, or designee, who handles requests for information/assistance from adoption agencies and attorneys as needed, unless previous arrangements have been made.• No information regarding the birth is to be given to anyone unless directly involved in the care of birth mother/infant.• The birth mother may see her infant, if desired.
  3. 3. Admission of birth mother• Birth mother is admitted to New Life Center per routine.• When notifying Admissions, specify that admission is “confidential”, if birth mother so requests.• Upon patient request, the Social Worker will be notified of patient (birth mother’s) admission and her desire for assistance with adoption.After Delivery of Infant• Immediately following delivery, the infant is taken to nursery (birth mother may see, if desired).• After recovery period, the birth mother is given the option to transfer to another room in the New Life Center away from the nursery, or transfer to another unit.
  4. 4. Admission of Infant• Follow routine admission procedure and care according to infant’s needs.• No crib card or card with no name, if birth mother requests infant to be confidential.• Keep crib away from viewing windows when blinds are open.• Associates may answer any questions from biological mother regarding infant, and she may see infant if desired.• Neonatal screening request contains infant’s gender and last name, with first name listed as “boy” or “girl,” address of adoption agency, adoption attorney, or petitioner for adoption (if known) is recorded. If infant is released to custody of Arkansas Department of Human Services, no address is recorded.
  5. 5. Admission of Infant• The birth certificate worksheet is completed as soon as possible with infant’s name listed as “boy” or “girl” if birth mother chooses not to name infant.• The biological mother signs all consent forms as she retains all legal rights until the relinquishment of parental rights is completed by the birth mother, and guardianship of infant is released to adoptive parents/attorney/agency.
  6. 6. Discharge of Infant1. The infant may be released to the petitioners for adoption, the attorney representing the petitioner for adoption, the Arkansas Department of Human Services, or the adoption agency representative upon completion of relinquishment of parental rights by the birth mother. Photo I.D. of the person taking the infant from the hospital shall be required.2. A copy of the executed release form (Appendix A), along with a copy of the photo I.D. of the person taking the infant from the hospital remains on the infant’s chart.
  7. 7. 4. A notation is made on infant’s chart showing: • Date and time infant was released • That a release form was properly executed; • Identity of person to whom the infant was released, and • That the identity of person to whom the infant was released was verified by a Photo I.D. Example: On December 1 2010, at 0900 baby Jones was released to the custody of Mr. John Smith, attorney, after a release form was properly executed, and Mr. Smith presented photo I.D. verifying his identity.5. Attorneys or others who inquire as to the procedure for releasing prospective adoptive children are given a copy of White County Medical Center“Statement to Assist Attorneys and Others With Regard to Adoption” (Appendix B).
  8. 8. 6600.0105 Appendix AEXHIBIT ARELEASE FORM AUTHORIZING WHITE COUNTY MEDICAL CENTERTO RELEASE CUSTODY OF A MINOR CHILDI, _________________________________, the undersigned biological mother of __________________________, a minor child currentlyin the New Life Center of White County Medical Center, hereby authorize and direct the release of said child from the New Life Center ofWhite County Medical Center to ______________________________________________.The person to whom release is authorized is (check one):_____ The petitioner of adoption_____ The guardian of the minor child_____ A representative of a child placement agency licensed under the Child Welfare Agency Licensing Act._____ A representative of the Division of Children and Family Services._____ An attorney on behalf of one of the foregoing.I hereby certify that I have executed either a (i) consent for adoption pursuant to Ark. Code Ann. Section 9-9-208, or (ii) a relinquishmentof parental rights pursuant to Ark. Code Ann. Section 9-9-220.I hereby further authorize the person to whom release is authorized to obtain any medical treatment, including circumcision of a malechild, reasonably necessary for the care of the minor and any physician or medical services provider to furnish additional services deemedreasonable and necessary.IN WITNESS WHEREOF, I have executed this Release Form as of the ___ day of _____________, 20____.Signature of biological mother: ___________________________________________Print name of biological mother: ____________________________________________(Witnesses must be credible, competent, age 18 or older and not an employee of White County Medical Center)_________________________________________ _______________________Witness Signature Date_________________________________________ _________________________Witness Signature Date
  9. 9. 6600.0105 Appendix AACKNOWLEDGEMENTSTATE OF ________________________ ) )COUNTY OF _______________________ ) On this day before me, a Notary Public, duly commissioned, qualified and acting within and for said county andstate, appeared the within named ____________________________, and acknowledged that he/she had so signed, executedand delivered said foregoing instrument for the consideration, uses and purposes therein mentioned and set forth.IN TESTIMONY WHEREOF, I have hereunto set my hand and seal this ________ day of ________, 20_____.___________________________NOTARY PUBLICMy Commission Expires:__________________________(SEAL)
  10. 10. 6600.0105 Appendix B WHITE COUNTY MEDICAL CENTER Statement to Assist Attorneys and Others With Regard to Adoption White County Medical Center is willing to assist attorneys and others with thesuccessful process of adoptions. In order to allow the adoption process to flowsmoothly, we have specific procedures that are to be followed in all adoption cases. We ask that your visits with the birth mother take place at pre-arranged times.Hospital personnel are instructed not to participate in or offer legal assistance to thebirth mother in executing a consent for adoption or to terminate parental rights. It is not necessary that White County Medical Center be named as a party toany adoption/guardianship proceeding. Finally, it is our policy to require a photo I.D. for verification of identity ofpersons to whom patient is released. Hospital personnel are instructed to obtain suchidentification and photocopy it for placement in patient’s medical record. We hope this information allows for a smooth and orderly process withregard to adoptions. If you have any questions, please feel free to contact our SocialWork Services Department.