Healthcare Consent for Surrogacy Form

HEALTHCARE CONSENT FOR SURROGACY FORM

Patient Identification

Patient Name:

Intended Parent(s) / Agents

Intended Parent(s) Name(s):

Insurance and Billing

Medical & Obstetric History

Obstetric History (G/P):

Consent for Medical and Reproductive Procedures

I, the undersigned patient, consent to undergo medical and obstetric care in connection with gestational surrogacy, including but not limited to diagnostic testing, ovulation monitoring, medication administration, embryo transfer procedures, prenatal care, labor management, delivery, anesthesia, and postpartum care as deemed necessary by the treating physicians and clinical staff.

Provider / Clinic Name:

I consent to the use of local or regional anesthesia and/or general anesthesia if medically indicated.
I consent to blood transfusion if necessary for life-saving or stabilizing care.
I consent to surgical intervention, including cesarean delivery, if medically indicated.
I consent to emergency diagnostic and therapeutic procedures, including transfer to another facility if required.

Risks, Benefits, and Alternatives

The treating clinician has explained to me the nature and purpose of the proposed treatments and procedures, the reasonable and material risks (including but not limited to infection, hemorrhage, thromboembolic event, anesthetic complications, adverse medication reactions, preterm delivery, fetal or neonatal injury, or maternal morbidity), and the reasonably available alternatives, including no treatment. I have had the opportunity to ask questions and understand that no outcome can be guaranteed.

HIPAA Authorization and Confidentiality

I authorize the disclosure of my protected health information related to fertility treatment and pregnancy to the Intended Parent(s), their legal representatives, and other persons designated below for purposes of treatment coordination, billing, and legal compliance. I understand I may revoke this authorization in writing except to the extent that action has already been taken in reliance upon it.

I acknowledge that I have received, read, and understand the facility's privacy practices and authorize release as stated above.

Legal Notice & Release

I understand that this Healthcare Consent for Surrogacy Form is limited to medical treatment and disclosure authorizations and does not constitute or replace any separate surrogacy contract, parenting agreement, or court order. I acknowledge that legal parentage and other legal obligations are addressed by separate legal instruments and applicable law.

I release the treating clinicians, facility, and staff from liability for routine complications of treatment when care is provided in accordance with accepted medical practice. I further authorize the release of medical records as necessary to coordinate care, to the extent permitted by law and this authorization.

Financial Responsibility

I understand that financial responsibility for medical services rendered is governed by the agreement(s) between the parties and the clinic. I acknowledge that I may be billed for services not covered by insurance or by third-party arrangements, and I agree to cooperate with billing and claims processes.

Authorization Period

This authorization for treatment and release of information will remain in effect until , unless earlier revoked in writing.

Additional Instructions / Limitations

Acknowledgement and Signature

By signing below I certify that I am the patient identified above (or legal guardian acting on behalf of the patient), that I have read and understand this Healthcare Consent for Surrogacy Form, that all my questions have been answered to my satisfaction, and that I consent to the medical treatments and authorizations contained herein.

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