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please complete the following authorization to finalize your application.
We will obtain the required medical records in order to evaluate your qualification.
One more step to complete your application. 95%

Authorization to Release Medical Records – Office Use

Patient's Full Name
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Field is required!
Do you have a maiden name?
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Field is required!
Date of Birth
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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 births (including surro babies)?
If there are twins, please count as one birth.
Field is required!
Field is required!
Have you been a surrogate before?
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Field is required!


Please provide Information for all your births

including surrogacy births, from oldest to youngest.


My 1st Child (Oldest)

This child was born on
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Field is required!
Physician's (OBGYN) Full Name
Field is required!
Field is required!
Clinic's name
Field is required!
Field is required!
Clinic Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Fax Number
Field is required!
Field is required!
Delivery Hospital for this child
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Field is required!
Hospital Address
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Field is required!
Phone Number
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Field is required!
Fax Number
Field is required!
Field is required!

Information for My 2nd Child

This child was born on
Field is required!
Field is required!
This child is
Field is required!
Field is required!
Did you use the same OB doctor and delivery hospital for this child?
Field is required!
Field is required!
Physician's (OBGYN) Full Name
Field is required!
Field is required!
Clinic's name
Field is required!
Field is required!
Clinic Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Fax Number
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
Field is required!
Field is required!

Information for My 3rd Child

This child was born on
Field is required!
Field is required!
This child is
Field is required!
Field is required!
Did you use the same OB doctor and delivery hospital for this child?
Field is required!
Field is required!
Physician's (OBGYN) Full Name
Field is required!
Field is required!
Clinic's name
Field is required!
Field is required!
Clinic Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Fax Number
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
Field is required!
Field is required!

Information for My 4th Child

This child was born on
Field is required!
Field is required!
This child is
Field is required!
Field is required!
Did you use the same OB doctor and delivery hospital for this child?
Field is required!
Field is required!
Physician's (OBGYN) Full Name
Field is required!
Field is required!
Clinic's name
Field is required!
Field is required!
Clinic Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Fax Number
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
Field is required!
Field is required!

Information for My 5th Child

This child was born on
Field is required!
Field is required!
This child is
Field is required!
Field is required!
Did you use the same OB doctor and delivery hospital for this child?
Field is required!
Field is required!
Physician's (OBGYN) Name
Field is required!
Field is required!
Clinic's name
Field is required!
Field is required!
Clinic Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Fax Number
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
Field is required!
Field is required!

Information for My IVF clinic

Only applicable if you were a surrogate before.
I authorize the following provider
Field is required!
Field is required!
Physician's Name
Field is required!
Field is required!
Clinic Address
Field is required!
Field is required!
Phone Number
Field is required!
Field is required!
Fax Number
Field is required!
Field is required!

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.com
I 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!
Field is required!
Field is required!
Date
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Field is required!