Form: Surrogacy Delivery at Baptist Health

I am the...

Expected Delivering Hospital

First Name	Last Name
Email Address	Phone Number

I represent:

Add another parent:

YesNo

Date of Birth

Do you know intended parents' name(s) and contact information?

YesNo

Parent #1

First Name (Parent #1)	Last Name (Parent #1)
Phone Number (Parent #1)	Email Address (Parent #1)
Add another parent: YesNo

Parent #2

First Name (Parent #2)	Last Name (Parent #2)
Phone Number (Parent #2)	Email Address (Parent #2)

Are you working with an agency, attorney or other representative?

YesNo

Representative

Agency Name

First Name (Representative)	Last Name (Representative)
Phone Number (Representative)	Email Address (Representative)

Do you know the surrogate's name and contact information?

YesNo

Surrogate Information

First Name (Surrogate)	Last Name (Surrogate)
Phone Number (Surrogate)	Email Address (Surrogate)

Delivery Information

Due Date

Number of Babies Due

Delivery services will be covered by:

Baby's care will be covered by:

Email Notification

UTM

utm_source

utm_medium

utm_campaign

utm_term

utm_content

Coverage Information

Delivery services will be covered by:

Insurance Information

Subscriber First Name	Subscriber Last Name
Insurance Name	Member ID

Self-Pay Contact Information

(50% deposit of estimated services is required.

First Name	Last Name
Phone Number	Email

Baby's care will be covered by:

Baby's Insurance Information

Subscriber First Name	Subscriber Last Name
Insurance Name	Member ID

Self-Pay Contact Information for Baby's Care

(50% deposit of estimated services is required.

First Name	Last Name
Phone Number	Email

Documents

Upload any documents needed at the time of birth (such as POA, Pre-birth order or PBO, Certified Judgment, Contract, etc.) to be facilitated with the hospital social worker and medical staff.

Additional Comments or Questions:

For additional assistance, call us at 904.202.4233.