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orange heart 1Welcome to the Surrogate Checklist.  Please refer to the list below to help guide you through the intake process.

Please complete all the forms listed below and provide copies of the requested documentation.

Surrogate

Please complete all the following forms by clicking on the name of the form.  You will be directed to the form.  Please complete the form and click on the submit button.  

If you need to save the form and return to it, you may click save and a link will be emailed to you to come back and complete the form.

Surrogate Intake Form

Surrogate Agreement Form

HIPAA Form

Authorization to Release Medical Records

Authorization to Release Records (General)

Photo Release Form

Background Check Agreement Form (use the password “surrogacy”)

 

Please email an image/photo of each of the following documentation to:  Carrie, Intake Specialist

Surrogate Photo Identification

Surrogate Vehicle Insurance

Surrogate Health Insurance Card

Surrogate Pay Stub

Please email 10-20 photos of you, your partner, your family, your home, etc. (Please use photos that give us an idea of who you and your family are…candid is great, posed are ok.  A variety is best.)

 

Surrogate Spouse/Partner 

Please complete all the following forms by clicking on the name of the form.  You will be directed to the form.  Please complete the form and click on the submit button.  

If you need to save the form and return to it, you may click save and a link will be emailed to you to come back and complete the form.

Spouse/Partner Background Check Agreement Form (use the password “surrogacy”)

Spouse/Partner HIPPA Form

Spouse/Partner  portion of the Surrogate Intake Form.  Please fill out and submit when the Surrogate Intake Form is filled out by your spouse/partner (the surrogate)

 

Please email an image/photo of each of the following documentation to: Carrie, Intake Specialist

Spouse/Partner Photo Identification

Spouse/Partner Pay Stub

 

If you have any questions or need assistance with the Surrogate Checklist, email Carrie  at carrie@hearttohandssurrogacy.com

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