Dear Potential Surrogate Mother:
Thank you for your interest in our program. If you would like the brochure that we typically send to surrogates, please let us know, and we will send it to you. Please follow these instructions carefully:
Complete the online application in its entirety. This is a lengthy application and should be completed in one sitting. Please allow plenty of time to carefully consider and answer each question.
Complete the online autobiographical questionnaire about you, your family, your spouse, etc. This is a form prepared by our psychologist and both you and your husband (or significant other if you are living with someone) need to fill it out separately.
Print and complete a medical records release form to be sent to whichever doctor(s) delivered your child(ren). It more than one doctor was involved, make a copy of this and give it to each doctor who would have your pregnancy records. DO NOT RETURN THIS FORM TO US. SEND IT TO YOUR DOCTOR.
Print and complete a criminal history release form to be delivered to your local law enforcement agency. DO NOT RETURN THIS FORM TO US. Take it or mail it to your local sheriff’s or police department. (You will need to download the 'Surrogate Application Part 2' form to complete steps 3)
Once I receive your application, I will review it and call you to go over it. I will also answer any questions you may have about the program. If you do not have a phone, you will need to call us from someone’s home a week after you’ve sent us the application. If you have not heard from us within a week, please contact us.
After the initial interview with me, I will draw up a profile sheet that summarizes the things the couples would want to know about you. That profile sheet is then shown to the couples that are looking for surrogates.
Once a couple indicates that they are interested in working with you, I will call you and give you the same type of information about the couple that I given them about you. You can decide if they sound like the type of people for whom you’d like to do this. If so, we will send your application to our psychologist, and he will call you to go over it and schedule a time for you to come here for the full psychological testing.
Because we have such an active surrogate program, it is important that you return the application as soon as possible. Please review the checklist included with this packet to make sure you’ve done everything we’ve asked. If you have any questions about any of this, feel free to call.
Thank you again for your interest in our program. You are about to become involved in a wonderfully rewarding experience, and you will be providing the most valuable gift imaginable to people who desperately want a child. We look forward to hearing from you.
Very Truly Yours,Steven C. Litz
To begin the application press the "Next" button below. (Reminder, please do not start this application unless you have adequate time to complete it)
TO ALL SURROGATES REGARDING HEALTH INSURANCE. AND EXPENSE REIMBURSEMENT
Because of some recent confusion over health insurance and how it applies to surrogacy, all potential applicants should read the following note carefully. Health insurance companies are in the business of making money. Pregnancy is expensive, and insurance companies do not like to pay for it. They like it even less in surrogate situations, but so long as their policies do not exempt surrogacy, they are legally obligated to pay for your pregnancy.
A few insurance companies have given us problems in this regard, so the first piece of advice is not to mention anything to your employer about the fact that you're thinking of being a surrogate. It's not that we're hiding anything from the insurance company; it's simply none of their business. If you became pregnant by your husband, they certainly wouldn't ask you who the father was, so why should that matter when the child is not his?
Secondly, and equally as important, if you currently have insurance you must use your own insurance to pay for your medical expenses. The reasons for this is that if you do not, then the couple would be required to take out a policy on you, and the application you would fill out would ask if you had insurance in force already. If you say that you do, then the new policy would apply only after the first one paid your bills. If you say that you don't, then you're lying and you'd be liable for fraud. So, if you do have insurance, but you do not want it to be used, DO NOT APPLY TO OUR PROGRAM.
As mentioned to you when you first called in, the couple pays for all of your travel expenses. They also will pay for your husband's travel when you come to Indianapolis to be screened psychologically, and when you travel to one of the cities for the initial screening for the AI or embryo transfer program (if you are involved with that program). For the actual nseminations and/or embryo transfers, your husband's presence is NOT required, and the couple will not pay for his travel. If you want him (or anyone else) to accompany you, that is fine, but it will be at your expense.
Also, while you are traveling, you get $100/day for your travel. This covers your meals, your and your husband's lost wages, and your childcare. These things are not reimbursed because requiring you to keep receipts and submit them to us was too much of a problem. So, you get a flat $100/day. So, for example, if you and your husband (if you are married) come here Friday night, and leave Sunday, you would be reimbursed $200.
Finally, should any of you wish to speak to other surrogates, we will be providing you with the names and phone numbers of dozens of women from across the country. Once you are accepted into the program, we will reimburse you for calls to any of these women, up to $10/month. Calls you make to your couple are always reimbursed, so long as they are not excessive (we had one surrogate who called her couple 25 times in one day).
BEFORE YOU COMPLETE THIS APPLICATION, PLEASE READ THE FOLLOWING IMPORTANT NOTICE AND SIGN THE STATEMENT THAT FOLLOWS IT. IF YOU CANNOT HONESTLY SIGN THIS, PLEASE DO NOT COMPLETE THE APPLICATION.
Recently we have had several surrogates who, after they applied and were accepted into our program, and were selected by our clients, decided that they really couldn’t participate in the program. This is devastating for our clients, embarrassing for us at SMI, and costly for our surrogates. Please complete this application only if you are ready now to be a surrogate if called upon by SMI and only if you can honestly respond "I agree" the statement below. It would be unkind and upsetting to our clients if you were to withdraw your application after they reviewed it and became hopeful about working with you.
Statement: I am ready now to be a surrogate if called upon by SMI. I understand that it would be unkind and upsetting to the people seeking to become parents if I were to withdraw my application after they reviewed it and became hopeful about working with me.
The "I’m Ready to be a Surrogate" Checklist
Lately, here at SMI we’ve had several surrogates who were selected, came to Indianapolis to be screened, then backed out of the program immediately after they were here. They gave a variety of reasons, but whatever they said didn’t matter. It was expensive for them, it was devastating for my clients, and it reflects poorly on my program. So, we’ve created this checklist for you to be absolutely sure that you are committed to doing this. We will invest a huge amount of time and money in you, and we do not want you to be a surrogate in our program unless you know that you are ready to proceed. With that in mind, please review every one of these statements, and check each one to make sure that you are willing to give the most wonderful gift in the world to our clients (and please note that every one of these situations has actually happened, however ridiculous it may seem).
Please complete and submit this application. Failure to respond to portions of the questionnaire or false answers will automatically eliminate you from the program. Please read the supplied information before answering these questions. Thank you.
Upload two good pictures of you and your family. If you have difficulty uploading the pictures, you can email them to email@example.com.
EDUCATION: Please list all schools attended and degrees received, beginning with high school
MEDICAL/SOCIAL HISTORY: Please answer the following questions to the best of your ability. If any questions are answered "yes," give a complete explanation at the end of this section
Have you, your children, or anyone in your family ever had any of the following:
During The past MONTH, have you OFTEN been bothered by...
Note: if you are not on the pill or using Norplant, you will need to keep track of your temperature, and we will send you the forms after we receive your application. After you have completed one month of charting, make a copy of the chart, and send it to us.
REFERENCES: Please list the names, addresses, and phone numbers of three (3) people other than family members who have known you for at least 5 years. Please discuss your participation in our program with them, so that when we contact them, they will know why we're calling.
DOCTORS' NAMES: Please list the names, addresses, and phone numbers of your current physician.
Fee Arrangement: Our typical fee for first time surrogates is $15,000; in the event of multiple births it is increased to $20,000.
These questions should be answered by both the surrogate applicant and her husband (or significant other if not married but living with someone), meaning that each of you must fill out this separately.
After you complete the entire application, you husband will have the opportunity to answer this portion as well. You will be provided a link to access that page, which your husband can answer as soon as you are finished.
Please try to answer the questions as completely and accurately as possible. The more you can tell us about yourself and your family, the better we will be able to evaluate you, and the better your chances will be of getting selected.
BECAUSE OF RECENT PROBLEMS WITH FAMILY MEMBERS OBJECTING TO SURROGACY, YOU ARE NOW REQUIRED TO DISCUSS YOUR PARTICIPATION IN THE PROGRAM WITH BOTH YOUR AND YOUR SPOUSE'S FAMILY. DO NOT SUBMIT THIS APPLICATION UNTIL YOU HAVE DONE SO.
BE SURE TO INCLUDE 2 RECENT PICTURES OF YOURSELF AND YOUR CHILDREN (IF YOU HAVE ANY) WITH THIS APPLICATION.
By filling out the enclosed application, returning it to Surrogate Mothers, Inc. ("SMI"), and upon notification that a couple is interested in working with me, I (meaning both myself and my husband if I am married) agree that:
1. If at any time within one year after the interview with the psychologist, I withdraw from the program for any reason without the couple's consent, I will refund to SMI the actual expenses incurred by the couple or by SMI on my behalf (for example, psychological screening, travel and lodging expenses, daily allowances, etc.), within ten (10) days after the attorney for the couple notifies me what those actual expenses are.
2. If at any time after a couple selects me to act as a surrogate mother (as described by the contract between the surrogate and the biological father or the couple), I become pregnant by any means other than by being artificially inseminated with the sperm from the biological father (or through artificial insemination with donor sperm if both the husband and the wife of the couple are infertile), or by having a successful embryo transplant, I will refund to SMI the actual costs incurred by the couple or SMI on my behalf up to the point that I became pregnant and notified the attorney for the couple of the pregnancy in writing.
3. If at any time after I have been screened psychologically and accepted into the program, I desire my own attorney, I am entitled to such representation, and I will be reimbursed up to $300 (or more if agreed upon in advance) for such representation.
4. If at any time after I have traveled to Indianapolis for psychological testing, it becomes apparent that I have misrepresented or lied about anything on the application or have not been truthful with the psychologist, I will be immediately rejected from the program, and the reimbursement provisions contained in Section 1 above shall apply.
6. I agree that attorneys fees are recoverable in the event of a lawsuit to enforce this agreement, that jurisdiction in the event of a lawsuit will be in the courts of Indiana, and that venue will be in Morgan County, Indiana.
7. I have read the above provisions, and by entering my initials below, I acknowledge that I understand the consequences of this agreement.
To complete this portion of the application press the "Submit" button below.