This required section provides information regarding an individual's consent to donate or the refusal to donate organs or tissues. There are no entry fields in this section. Press [Ctrl+F1] for more information.
This required section allows a Donor to state which organs or tissues are to be donated at the Donor's death. The Donor is the person donating organs, tissues or parts to be removed after death. Press [Ctrl+F1] for more information.
This optional section allows the Donor to indicate specific limitations or wishes concerning the donation of the Donor's organs, tissues, or parts. Press [Ctrl+F1] for more information.
This optional section allows the Donor to revoke or amend previous organ donation documents. Press [Ctrl+F1] for more information.
This optional section provides that the inclusion of an invalid request or instruction does not invalidate the other provisions of the document. Press [Ctrl+F1] for more information.
This required section provides for the appropriate signatures on the Organ Donation Form. Press [Ctrl+F1] for more information.
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Mississippi Organ Donation Form
ORGAMS
The Mississippi Organ Donation Form, as authorized by Mississippi law, allows a person to state his/her intent to make an "anatomical gift" of organs or tissues after the Donor's death, specify how the donated items should be used, and designate who will receive such items.
OMS01
! Information Section (1 of 6)
ORGAN DONATION FORM
[THIS DOCUMENT ALLOWS INDIVIDUALS TO DONATE THEIR ORGANS, TISSUES, OR PARTS. THE ACTUAL DONATION TAKES EFFECT AFTER THE INDIVIDUAL'S DEATH. THIS DOCUMENT MAY BE USED TO:
* MAKE AN ORGAN DONATION IF AN INDIVIDUAL HAS NEVER BEFORE COMPLETED A DONOR FORM
* MAKE A NEW ORGAN DONATION AND REVOKE OR AMEND A PRIOR DONATION
* MAKE AN ORGAN DONATION IF AN INDIVIDUAL HAS PREVIOUSLY REFUSED TO MAKE AN ORGAN DONATION]
[FOR INDIVIDUALS WHO DO NOT WANT TO BE ORGAN DONORS, THIS PROGRAM PROVIDES THE "REFUSAL TO DONATE FORM". THAT DOCUMENT MAY BE USED TO:
* DOCUMENT THE REFUSAL TO MAKE AN ORGAN DONATION
* REVOKE A PRIOR ORGAN DONATION AND DOCUMENT THE REFUSAL TO MAKE AN ORGAN DONATION]
OMS02
! Donation Section (2 of 6)
[ALL SECTIONS LABELED "OPTIONAL" IN THIS FORM ARE ADDITIONS TO THE STANDARD FORM PROVIDED IN MISSISSIPPI LAW. THE OPTIONS ARE EITHER CONSISTENT WITH MISSISSIPPI LAW OR MISSISSIPPI LAW IS SILENT ON THE PARTICULAR OPTION. THE HINTS AND DOCUMENT INFORMATION FURTHER DISCUSS OPTIONAL SECTIONS.]
CERTIFICATE OF AUTHORIZATION OF POST-MORTEM
STUDY AND EXAMINATION OR REMOVAL OF TISSUES
OR ORGANS
I, the undersigned, this _____ day of _______________, 19___, desiring that my
(1) Any licensed hospital, surgeon or physician, for medical education, research, advancement of medical science, therapy or transplantation to individuals;
(2) Any accredited medical school, college or university engaged in medical education or research, for therapy, educational research or medical science purposes or any accredited school of mortuary science;
(3) Any person operating a bank or storage facility for blood, arteries, eyes, pituitaries, or other human parts, for use in medical education, research, therapy or transplantation to individuals;
(4) The donee specified below, for therapy or transplantation needed by him or her, do hereby donate my ! for said purpose to ! (Name) at ! (Address).
I hereby authorize a licensed physician, surgeon or certified technician or the state anatomy board to remove and preserve for use my
! organs, tissues, or parts as designated above
! [other]
for said purpose.
Enter an X if the Donor desires that any needed organs, tissues, or parts be donated at the Donor's death. The "Donor" is the individual donating organs, tissues, or parts. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires that any needed organs, tissues, or parts be donated at the Donor's death EXCEPT for one or two specific organs that the Donor desires NOT to be removed at death. Press [Ctrl+F1] for more information.
Enter a description of the specific organs, tissues, or parts that should NOT be removed from the Donor's body at death. For example, "heart" or "eyes". Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to specify only selected organs, tissues, or parts to be removed upon the Donor's death. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to donate the heart at death.
Enter an X if the Donor desires to donate heart valves at death.
Enter an X if the Donor desires to donate lungs at death.
Enter an X if the Donor desires to donate kidneys at death.
Enter an X if the Donor desires to donate the liver at death.
Enter an X if the Donor desires to donate the pancreas at death.
Enter an X if the Donor desires to donate intestines at death.
Enter an X if the Donor desires to donate bone at death.
Enter an X if the Donor desires to donate skin at death.
Enter an X if the Donor desires to donate blood vessels at death.
Enter an X if the Donor desires to donate eyes at death.
Enter an X if the Donor desires to donate musculoskeletal structures at death.
Enter an X if the Donor desires to donate body fluids at death.
Enter an X if the Donor desires to donate other tissue or cells at death.
Enter an X if the Donor desires to specify other organs, tissues, or parts to be donated at the Donor's death.
Enter a description of the organs, tissues, or parts the Donor desires to donate.
Enter a description of the organs, tissues, or parts the Donor desires to donate to a specific individual for transplantation or therapy. For example, "kidney" or "liver".
Enter the name of a specific individual who the Donor desires to receive the Donor's organs, tissues, or parts, or use the P.I. Manager to select and paste a record.
Enter the address of the individual designated to receive the donated organs and tissues.
Enter an X if the Donor donated organs, tissues, or parts on this form. Mississippi law does not provide instructions with the Mississippi form. It appears that the intent is to give a general description of what is donated on the form.
Enter an X if the Donor indicated on this form something other than "organs, tissues, or parts" to be made available after death.
Enter a description of what the Donor authorized to be available after death.
OMS03
! Optional Special Limitations Section (3 of 6)
Limitations or special wishes, if any:
Enter an X to include this OPTIONAL section that allows the Donor to indicate any specific limitations or wishes concerning the donation. Mississippi law does not address special limitations. Press [Ctrl+F1] for more information.
Enter a description of the Donor's special wishes. For example, "Use in Mississippi, if possible", "Dr. Jones to perform the procedure, if possible", or "for transplantation only".
OMS04
! Optional Revocation or Amendment of Prior Document Section (4 of 6)
[WARNING: A DONOR MAY NEED TO DO MORE THAN COMPLETE THIS OPTIONAL SECTION TO ASSURE A NEW ORGAN DONATION FORM IS HONORED AT A DONOR'S DEATH. FOR EXAMPLE IF AN ORIGINAL DONOR FORM WAS DELIVERED TO A HOSPITAL OR PHYSICIAN, THEY SHOULD BE NOTIFIED IF IT IS REVOKED. FOR MORE HELP, ACCESS DOCUMENT INFORMATION.]
[WARNING: IF AN INDIVIDUAL WANTS TO REVOKE A PRIOR DONATION AND DOES NOT WANT TO MAKE A NEW DONATION, THE "REFUSAL TO DONATE FORM" SHOULD BE COMPLETED INSTEAD OF THIS DOCUMENT.]
! I revoke any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. I intend for this document to direct the removal and use of my organs, tissues, or parts at my death.
! I amend any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. To the extent this document is inconsistent with or more complete than any previously completed form, I intend for this document to amend or supplement the previous document.
! I hereby revoke any previous document or writing where I indicated my refusal to donate my organs, tissues, or parts after my death.
Enter an X to include this OPTIONAL section that allows the Donor to revoke or amend previous documents. Mississippi law provides that a Donor may revoke a donation by a signed statement. A Donor may need to do more than complete this section to assure the new Form is honored. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to revoke a previous document or writing where the Donor's organs, tissues, or parts were donated. If a Donor wishes to revoke a prior donation and does not want to make a new one, it is recommended that a "Refusal to Donate Form" be completed.
Enter an X if the Donor desires to amend a previous organ donation form. It is recommended that a Donor read Document Information before selecting this option. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to revoke a previous document indicating the Donor's refusal to donate organs. If a Donor previously completed a "refusal" document and is now making a donation, that Donor should select this option.
OMS05
! Optional Severability Section (5 of 6)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this OPTIONAL severability clause be included to prevent one invalid provision from invalidating the entire document. Mississippi law does not address severability clauses in forms. If you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for more information.
Signature of Donor's Representative who signs on behalf of the Donor at the direction of and in the presence of the Donor who is physically unable to sign and in the presence of two witnesses:
Signature of Donor's Parent who consents to the Donor's donation as directed in this document and signs in the presence of the Donor and in the presence of two witnesses:
Signature of Donor's Guardian who consents to the Donor's donation as directed in this document and signs in the presence of the Donor and in the presence of two witnesses:
Enter the name of the Donor or edit the information as desired. Use the P.I. Manager to select and paste a record. Donor's generally should be "competent" to execute a valid donation form. Press [Ctrl+F1] for more information.
Enter the Donor's street address or edit the information as desired.
Enter the Donor's extended street address or edit the information as desired.
Enter the Donor's city or edit the information as desired.
Enter the Donor's state or edit the information as desired.
Enter the Donor's zip code or edit the information as desired.
Enter an X to include the Donor's country.
Enter the country or edit the information as desired.
Enter the Donor's telephone number or edit the information as desired.
Enter an X to include this OPTIONAL section if the Donor is physically unable to sign the document and another individual will sign on the Donor's behalf. Mississippi law allows for an individual to sign on behalf of a Donor who is physically unable to sign the document.
Enter the name of the individual who will sign on the Donor's behalf or use the P.I. Manager to select and paste a record. The name of the individual may be left blank and be completed when the document is signed.
Enter an X to include this OPTIONAL section if the Donor is a minor and the Donor's parent consents to the donation and will sign the form. Mississippi law does NOT provide that a form completed by a minor is valid. However, a completed form documents a minor's wishes and may be helpful to the minor's family. Press [Ctrl+F1] for more information.
Enter the name of the parent who will sign on the Donor's behalf or use the P.I. Manager to select and paste a record. The name of the parent may be left blank and be completed when the document is signed.
Enter an X to include this OPTIONAL section if the Donor is a minor and the Donor's guardian consents to the donation and will sign the form. Mississippi law does NOT provide that a form completed by a minor is valid. However, a completed form documents a minor's wishes and may be helpful to the minor's family. Press [Ctrl+F1] for more information.
Enter the name of the guardian who will sign on the Donor's behalf or use the P.I. Manager to select and paste a record. The name of the guardian may be left blank and be completed when the document is signed.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. It is generally recommended that the witness not have a special interest in the donation.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. It is generally recommended that the witness not have a special interest in the donation.
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