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. 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. 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. 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. Discharge of Infant
1. 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. 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. 6600.0105
Appendix A
EXHIBIT A
RELEASE FORM AUTHORIZING WHITE COUNTY MEDICAL CENTER
TO RELEASE CUSTODY OF A MINOR CHILD
I, _________________________________, the undersigned biological mother of __________________________, a minor child currently
in the New Life Center of White County Medical Center, hereby authorize and direct the release of said child from the New Life Center of
White 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 relinquishment
of 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 male
child, reasonably necessary for the care of the minor and any physician or medical services provider to furnish additional services deemed
reasonable 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. 6600.0105
Appendix A
ACKNOWLEDGEMENT
STATE OF ________________________ )
)
COUNTY OF _______________________ )
On this day before me, a Notary Public, duly commissioned, qualified and acting within and for said county and
state, appeared the within named ____________________________, and acknowledged that he/she had so signed, executed
and 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 PUBLIC
My Commission Expires:
__________________________
(SEAL)
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 the
successful process of adoptions. In order to allow the adoption process to flow
smoothly, 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 the
birth 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 to
any adoption/guardianship proceeding.
Finally, it is our policy to require a photo I.D. for verification of identity of
persons to whom patient is released. Hospital personnel are instructed to obtain such
identification and photocopy it for placement in patient’s medical record.
We hope this information allows for a smooth and orderly process with
regard to adoptions. If you have any questions, please feel free to contact our Social
Work Services Department.
