Your application has been completed 95% Please allow us 3-5 business days to review your submission. Meanwhile, please complete the following authorization to finalize your application. Authorization to Release Medical Records – Office UsePatient's Full NameField is required!Field is required!Do you have a maiden name?Field is required!Field is required!Date of BirthField is required!Field is required!In Pursuant to the Health Insurance Portability and Accountability Act (HIPPA) I hereby authorize the release of my records. I will assume the total responsibility of my copied medical records.NOTE: We need the information of your OBGyn Dr and delivery hospitals for all your children. From the youngest to the oldest.What is the total number of your children?123456Field is required!Field is required!Have you been a surrogate before?Yes.No. This is my first time.Field is required!Field is required!Information for My 1st Child (oldest)I authorize the following provider : Field is required!Field is required!Physician's NameField is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number (Leave blank if you dont know.):Field is required!Field is required!Delivery Hospital for this child:Field is required!Field is required!Hospital Address:Field is required!Field is required!Phone Number:Field is required!Field is required!Fax Number (Leave blank if you dont know.):Field is required!Field is required!Information for My 2nd ChildDid you use the same OB doctor and delivery hospital for this child?Same OB doctor and same delivery hospital. Same OB doctor, different delivery hospital. Different OB doctor, same delivery hospital. Different OB doctor, different delivery hospital.Field is required!Field is required!I authorize the following provider : Field is required!Field is required!Physician's NameField is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_2}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_2}","logic_and":"equal","value_and":"same_different"}]Delivery Hospital for this child:Field is required!Field is required!Hospital Address:Field is required!Field is required!Phone Number:Field is required!Field is required!Fax Number (Leave blank if you dont know.):Field is required!Field is required![{"field":"{doctor_hospital_2}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_2}","logic_and":"equal","value_and":"different_same"}][{"field":"{children_number}","logic":"greater_than","value":"1","and_method":"","field_and":"","logic_and":"","value_and":""}]Information for My 3rd ChildDid you use the same OB doctor and delivery hospital for this child?Same OB doctor and same delivery hospital. Same OB doctor, different delivery hospital. Different OB doctor, same delivery hospital. Different OB doctor, different delivery hospital.Field is required!Field is required!I authorize the following provider : Field is required!Field is required!Physician's NameField is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number (Leave blank if you dont know.):Field is required!Field is required![{"field":"{doctor_hospital_3}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_3}","logic_and":"equal","value_and":"same_different"}]Delivery Hospital for this child:Field is required!Field is required!Hospital Address:Field is required!Field is required!Phone Number:Field is required!Field is required!Fax Number (Leave blank if you dont know.):Field is required!Field is required![{"field":"{doctor_hospital_3}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_3}","logic_and":"equal","value_and":"different_same"}][{"field":"{children_number}","logic":"greater_than","value":"2","and_method":"","field_and":"","logic_and":"","value_and":""}]Information for My 4th ChildDid you use the same OB doctor and delivery hospital for this child?Same OB doctor and same delivery hospital. Same OB doctor, different delivery hospital. Different OB doctor, same delivery hospital. Different OB doctor, different delivery hospital.Field is required!Field is required!I authorize the following provider : Field is required!Field is required!Physician's NameField is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_4}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_4}","logic_and":"equal","value_and":"same_different"}]Delivery Hospital for this child:Field is required!Field is required!Hospital Address:Field is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_4}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_4}","logic_and":"equal","value_and":"different_same"}][{"field":"{children_number}","logic":"greater_than","value":"3","and_method":"","field_and":"","logic_and":"","value_and":""}]Information for My 5th ChildDid you use the same OB doctor and delivery hospital for this child?Same OB doctor and same delivery hospital. Same OB doctor, different delivery hospital. Different OB doctor, same delivery hospital. Different OB doctor, different delivery hospital.Field is required!Field is required!I authorize the following provider : Field is required!Field is required!Physician's NameField is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_5}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_5}","logic_and":"equal","value_and":"same_different"}]Delivery Hospital for this child:Field is required!Field is required!Hospital Address:Field is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_5}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_5}","logic_and":"equal","value_and":"different_same"}][{"field":"{children_number}","logic":"greater_than","value":"4","and_method":"","field_and":"","logic_and":"","value_and":""}]Information for My 6th ChildDid you use the same OB doctor and delivery hospital for this child?Same OB doctor and same delivery hospital. Same OB doctor, different delivery hospital. Different OB doctor, same delivery hospital. Different OB doctor, different delivery hospital.Field is required!Field is required!I authorize the following provider : Field is required!Field is required!Physician's NameField is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_6}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_6}","logic_and":"equal","value_and":"same_different"}]Delivery Hospital for this child:Field is required!Field is required!Hospital Address:Field is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{doctor_hospital_6}","logic":"equal","value":"same_same","and_method":"or","field_and":"{doctor_hospital_6}","logic_and":"equal","value_and":"different_same"}][{"field":"{children_number}","logic":"greater_than","value":"5","and_method":"","field_and":"","logic_and":"","value_and":""}]Information for My IVF clinicOnly applicable if you were a surrogate before.I authorize the following provider : Field is required!Field is required!Physician's Name[{"field":"{citizenship}","logic":"equal","value":"status_other","and_method":"","field_and":"","logic_and":"","value_and":""}]Field is required!Field is required!Clinic AddressField is required!Field is required!Phone Number:Field is required!Field is required!Fax Number:Field is required!Field is required![{"field":"{surrogate_before}","logic":"equal","value":"yes","and_method":"","field_and":"","logic_and":"","value_and":""}]to disclose the following protected health information: Time Frame: All the time available. Pregnancy related medical records（Pregnancy Office visits, Hospital delivery and discharge records , Lab results） Sensitive information including but not limited to: 1) HIV/AIDS, communicable diseases; 2) Drug/alcohol treatment/evaluation 3O Mental health treatment/evaluation 4) Genetic testing The medical records should be either faxed or mailed to the recipient below:Attn: FindTheSurrogate LLC By Fax: 925 800 3460 By Email: info@findthesurrogate.comI hereby state that I hold the right to revoke this authorization and I am aware that the records may be re-disclosed and no longer be protected. This authorization will expire in 90 days from dated.Field is required!Field is required!Date:Field is required!Field is required!Submit
