Directed Donor Initial Questionnaire

If you are an out-of-state applicant, please be aware that during your retrieval cycle you will need to do multiple office visits consisting of ultrasounds and lab work along with the retrieval at our clinic in Woodbury, Minnesota. This is usually a 2 week period. There is also an appointment in the screening process that must take place at our clinic as well for FDA compliance. If you are aware and comfortable with these requirements, you may proceed with submitting your application. If you are not comfortable with these requirements, we would not recommend submitting your application and appreciate your time and interest in our program.*

I understand these requirements and wish to proceed at this time
Name*

First NameMiddle NameLast Name
Patient DOB*

MonthDayYear
Date
Marital status
Patient Race*
Patient ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile phone*

Area CodePhone Number
Email*
example@example.com
Email contact if you are working through an agency
example@example.com
Patient height and weight*
Partner name*

First NameMiddle NameLast Name
Partner DOB*

MonthDayYear
Date
Who are you donating for?
(Name of intended parent)
How did you find out about RMIA?*
Are you a current cigarette smoker?*
Do you consume alcohol, if so, approximately how many per week?
Have you ever been pregnant?*
How many live birth(s)?*
Delivery*

Vaginal deliveryC-sectionOther
How many miscarriage/abortion(s)?*
Are you adopted?
Hobbies (ie. skating, dancing, traveling, etc.)
Have you donated your eggs before?
Do you or your partner have any flu-like symptoms (cough, fever, shortness of breath)?*
Have you been in close contact with someone who has been diagnosed with COVID-19 within the last 14 days?*
Have you been tested for COVID-19 and awaiting results? *
Have you been requested to self-quarantine?*
Have you traveled to an area affected by the Ebola virus in the last 21 days? *
Have you traveled to an area affected by the Zika virus in the last 8 weeks (6 months for men)?*
Do you have plans to travel to a Zika affected area in the next 6 months?*
Upload/take photo of Patient VALID identification (license, passport)*

Contact Preference and HIPAA Consent to Leave Messages
Reproductive Medicine & Infertility Associates (RMIA) gives patients the option to choose a preferred method in which to communicated medical information.
Which location can we leave a message?
Phone Number*
Please enter a valid phone number
Patient Name

First NameLast Name
Patient Signature

Clear
Partner Name

First NameLast Name
Partner Signature

Clear
Date

MonthDayYear
Date

Email Consent Form
EMERGENCY PROBLEMS
E-mail should never be used for emergency situations. In the event of an emergency, call 911 URGENT PROBLEMS

E-mail should never be used for urgent situations. In these cases, the patient should call our main number 651-222-6050 during business hours (M-F 7:30-4:30). After hours you can contact our on call answering service or go to an urgent care.

1. RISKS OF USING E-MAIL TO COMMUNICATE WITH YOUR CLINIC
Reproductive Medicine & Infertility Associates referred throughout this consent as “Clinic.” The Clinic offers patients the opportunity to communicate by e-mail. Transmitting patient information by email, however, has a number of risks that patient should consider before using e-mail to communicate with the Clinic. These include, but not limited to, the following risks:
- E-mail can be circulated, forwarded, and stored in numerous paper and electronic files
- E-mail sender can type in the wrong email address
- Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
- Employers have a right to archive and inspect e-mails transmitted through their system.
- E-mails can be used to introduce viruses into computer systems
- E-mail can be intercepted, altered, forwarded, or used without authorization or detection.
- E-mails can be used as evidence in court.
2. CONDITIONS FOR THE USE OF E-MAIL
Provider will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, because of the risks outlined above, the Clinic cannot guarantee the security and confidentiality of e-mail communication and will not be liable for improper disclosure and confidential
information that is not caused by the Clinics intentional misconduct. Thus, patient must consents to the use of e-mail for patient information. Consent to the use of e-mail includes agreement with the following conditions:

a) All e-mails concerning diagnosis or treatment will become part of the patients medical records.

b) Patient shall not use e-mails for medical emergencies, urgent problems or other sensitive matters.

c) If the patient has not received a response back from the Clinic within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the e-mail and when the recipient will respond.

d) The patient acknowledges the risk in using e-mail for communication regarding sensitive medical information, such as information regarding, but not limited to laboratory testing, mental health, or health history.

e) The patient is responsible for protecting his/her password or other means of access to e-mail. The Clinic is not liable for breaches of confidentiality caused by the patient or any third party.

f) Clinic shall not engage in e-mail communication that is unlawful.

g) It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.

3. PATIENT RESPONSIBILITIES AND INSTRUCTIONS
To communicate by e-mail, the patient shall:
a) Limit or avoid use of his/her employer’s computer

b) Inform Clinic of changes in his/her e-mail

c) Put the patient’s name in the body of the e-mail.

d) Include the category of the communication in the e-mail’s subject line

e) Review the e-mail to make sure it is clear and that all relevant information is provided before sending the e-mail.

f) Take precautions to preserve the confidentiality of the e-mail, such as using screen savers and safeguarding his/her computer password.

4. ALTERNATE FORMS OF COMMUNICATION
I understand that I may also communicate with the Clinic via telephone or during a scheduled appointment and that e-mail is not a substitute for the care that may be provided during an office visit. Appointment should be made to discuss any new issues as well as sensitive medical information. I also understand that the Clinic also utilizes Notify MD as I go through active treatment and that is also a way to communicate results and changes in my treatment plan.

5. TYPES OF E-MAIL TRANMISSIONS THAT PATIENT AGREES TO SEND AND/OR RECEIVE

The types of information that can be communicated by e-mail with the Clinic include prescription refills, patient referrals and appointment scheduling reminders and requests, billing and insurance questions, consultation summaries, signed consent forms, IVF treatment plan (calendar) and instructions, and patient education. If you are not sure if the issue you wish to discuss should be included in an e-mail, you should call the Clinic to schedule an appointment. If you elect not to provide us with your email, but contact us through e-mail, we will
correspond to any email sent to us. In most occasions, you will receive an encrypted email via ZixMail. You must provide a username and password to log into ZixMail to retrieve your message(s). The Clinic will be notified of any message not picked up. The Clinic will make one attempt to resend via ZixMail or will mail document(s) to you. If you do not receive our email(s), please check your spam or junk mail folder. If you find it there, please identify it as “non-junk” or “non-spam” email. You may also want to add noreply@rmia.com to your contact or ‘Safe Sender’ list so that these emails do not go to your junk mail folder.

6. SECURITY MEASURES USED BY CLINIC
As stated above, communication via e-mail does come with privacy risks as stated above. While the Clinic can not guarantee total confidentiality, the Clinic will use reasonable safeguards to protect your health information as required by law.

7. HOLD HARMLESS
I agree to hold harmless the Providers, Reproductive Medicine & Infertility Associates, its employees, and website designers against all losses, expenses, damages, costs, including attorney’s fees, relating to information loss due to technical failure. The Clinic does not warrant that the functions contained in any material provided will be uninterrupted or error-free, that defects will be corrected, or that the Clinic website or server that makes such site available is free of viruses or other harmful components.

PATIENT ACKNOWLEDGEMENT AND AGREEMENT
I have discussed with the Clinic representative and we acknowledge that I have read and fully understand the consent form. We understand the risks associated with the communication of e-mail between the Clinic and us, and consent to the conditions herein.
Patient Email*
example@example.com
Patient Name

First NameLast Name
Patient Signature

Clear

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Protected Health Information (PHI) may include information/documents regarding medical treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test results; account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third party financing.

HIPAA regulations authorize the release of PHI for the purpose of treatment, obtaining payment from third party payers, and the day-to-day healthcare operations of Reproductive Medicine &Infertility Associates (RMIA). Other than those releases authorized by HIPAA, PHI will only be released to persons listed on this Authorization below.

This Authorization is voluntary and only applies to protected health information related to medical care received by RMIA.
Treatment or payment for services are not conditioned on signing the authorization.

I understand that the information that is used or disclosed in accordance with this Authorization may be subject to re-disclosure by the Recipient(s) listed below and, in that case, will no longer be protected by HIPAA.

I understand that I may revoke this authorization at any time prior to its expiration date by providing written notification to Michael Stein, Privacy Officer, Reproductive Medicine & Infertility Associates, 2101 Woodwinds Drive, Suite 100, Woodbury, MN 55125, but the revocation will not have any effect on any actions taken in reliance of this authorization or relating to the use or disclosure of the protected health information that RMIA took before it received the revocation.
This Authorization shall remain in effect until either: (a) its expiration date of 3 years, from today Date or (b) RMIA receives a written revocation of the authorization.
Select one:

Okay to share my medical information with person named below including test resultsNo, do not share my medical information with anyone ED 597 needed
I, First Name Last Name, hereby authorize the use or disclosure of my personal health information to the following person(s): First Name Last Name (if a second person such as gestational carrier/donor/parent: First Name Last Name
I, First Name Last Name, hereby decline authorization to use or disclose my protected health information to anyone (patient must also sign "HIPAA Request for Limitations & Restrictions of PHI" - ED-597).
Patient Signature

Clear
Date

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
During your treatment at Reproductive Medicine and Infertility Associates, P.A. and/or its subsidiary, Infertility Lab and Specialty Center, P.A. (collectively referred to herein as “RMIA”), doctors, nurses, and other caregivers may gather information about your medical history and your current health. This notice explains how that information may be used and shared with others. It also explains your privacy rights regarding this kind of information. The terms of this notice apply to health information created or received by RMIA. We are required by law to: make sure that medical information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms of the notice that is currently in effect.

Practices/Locations Covered by this Notice
This Notice of Privacy Practices applies to all practice locations and facilities of RMIA, along with its related sites. Please visit our website, www.rmia.com, for a complete list of our locations and facilities.

Your medical information may be used and disclosed for the following purposes:
- Treatment: We may use your information to provide, coordinate, and manage your care and treatment. For example, your physician may share your medical information with another physicianfor a consultation or a referral.
- Payment: We may use and disclose medical information about you so that the treatment and services you receive may be billed to, and payment may be collected from, you, an insurance company, or another third party. For example, we may need to give your health plan information about treatment you received at RMIA so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
- Health Care Operations: We may use and disclose medical information about you for RMIA’s health care operations. Health care operations are the uses and disclosures of information that are necessary to run RMIA and to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services, business planning and business management, and to evaluate and improve the performance of our staff and physicians in caring for you.
  Minnesota Patients: Minnesota law generally requires patient consent for disclosures of health records for treatment, payment and health care operations purposes, unless the disclosure is to a related provider for current treatment, consent is not possible due to a medical emergency, or the release is authorized by law. Absent one of these exceptions, we will get your written consent prior to making disclosures outside RMIA for treatment, payment or health care operations purposes.
- Fundraising: Occasionally, RMIA may use limited information (your name, address, and the dates you were seen for medical services) to let you know about fundraising or other charitable events. You have the right to request that we not send you information about fund-raising. If you would prefer that RMIA not notify you about fundraising events, please notify the Privacy Officer.
- To People Assisting in Your Care. RMIA will only disclose medical information to those taking care of you, helping you to pay your bills, or other close family members or friends if these people need to know this information to help you, and then only to the extent permitted by law. We may, for example, provide limited medical information to allow a family member to pick up a prescription for you. Generally, we will get your written consent prior to making disclosures about you to family or friends. If you are able to make your own health care decisions, RMIA will ask your permission
  before using your medical information for these purposes. If you are unable to make health care decisions, RMIA will disclose relevant medical information to family members or other responsible people if we feel it is in your best interest to do so, including in an emergency situation.
- Research: Federal law permits RMIA to use and disclose medical information about you for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate. Private pay patients in Wisconsin may deny access to researchers by annually submitting to RMIA a signed, written request on a form provided by the Wisconsin Department of Health Services.
  Minnesota and Wisconsin law generally requires that we get your general consent before we disclose your health information to an external researcher. We will make a good faith effort to obtain your consent or refusal to participate in external research, as required by law, prior to releasing any identifiable information about you to external researchers.
- As Required by Law: We will disclose medical information about you when we are required to do so by federal, state or local law.
- To Avert a Serious Threat to Health or Safety: Minnesota Patients: We may use and disclose medical information about you when necessary to
  prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure must be only to someone able to help prevent the threat. Minnesota law generally does not permit these disclosures unless we have your written consent to do so or when the disclosure is specifically required by law, including the limited circumstances in which RMIA health care professionals have a “duty to warn.” Wisconsin Patients: We may use and disclose medical information about you when your life or health appears to be in danger and the information contained in the patient health care records may aid the person in rendering assistance.
- To Business Associates: Some services are provided by or to RMIA through contracts with business associates. Examples include RMIA’s attorneys, management service company, consultants, collection agencies, and accreditation organizations. We may disclose information about you to our business associate so that they can perform the job we have contracted with them to do. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to redisclose the information unless specifically permitted by law.
Your medical information may be released in the following special situations:
- Organ and Tissue Donation: We may release your medical information to organizations that handle organ procurement or organ, eye or tissue transplantation, or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. The information that RMIA may disclose is limited to the information necessary to make a transplant possible.
- Military and Veterans: If you are a member of the armed forces, we will release medical information about you as requested by military command authorities if we are required to do so by law, or when we have your written consent. We may also release medical information about foreign military personnel to the appropriate foreign military authority as required by law or with written consent.
- Workers’ Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness. We are permitted to disclose information regarding your work-related injury to your employer or your employer’s workers’ compensation insurer without your specific consent, so long
  as the information is related to a workers’ compensation claim.
- Public Health: We may disclose medical information to public health authorities about you for public health activities. These disclosures generally include the following:
  - Preventing or controlling disease, injury or disability;
  - Reporting births and deaths;
  - Reporting child abuse or neglect, or abuse of a vulnerable adult;
  - Reporting reactions to medications or problems with products;
  - Notifying people of recalls of products they may be using;
  - Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
  - Reporting to the FDA as permitted or required by law; or
  - In Wisconsin, reporting to the Department of Transportation if you cannot exercise reasonable and ordinary care over a vehicle.
- Health Oversight Activities: RMIA may disclose medical information to a health oversight agency for health oversight activities that are authorized by law. These oversight activities include, for example, government audits, investigations, inspections, and licensure activities. These activities are
  necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
  Minnesota Patients: Minnesota law requires that patient-identifying information (for example, your name, social security number, etc.) be removed from most disclosures for health oversight purposes,
  unless you have provided us with written consent for the disclosure. Wisconsin Patients: Wisconsin law requires us to deny access to state or federal government agencies when they attempt to perform oversight functions if a private pay patient submits to us a written request on the form provided by the Wisconsin Department of Health Services.
- Lawsuits and Disputes: If you are involved in a lawsuit, dispute, or other judicial proceeding, we will disclose medical information about you only in response to a valid court order, or with your written consent.
  Law Enforcement: We may release medical information if asked to do so by a law enforcement official in response to a valid court order or with your written consent. In addition, we are required to report certain types of wounds, such as gunshot wounds and some burns. In most cases, reports will include only the fact of injury, and any additional disclosures would require your consent or a court order.
  We may also release information to law enforcement that is not a part of the health record (in other words, non-medical information) for the following reasons:
  - To identify or locate a suspect, fugitive, material witness, or missing person;
  - If you are the victim of a crime, if, under certain limited circumstances, we are unable to obtain your agreement;
  - About a death we believe may be the result of criminal conduct;
  - About criminal conduct at our facility; and
  - In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
- Coroners, Medical Examiners, and Funeral Directors: We will release medical information to a coroner or medical examiner in the case of certain types of death, and we must disclose health records upon the request of the coroner or medical examiner. This may be necessary, for example, to identify you or determine the cause of death. We may also release the fact of death and certain demographic information about you to funeral directors as necessary to carry out their duties. Other disclosures from your health record will require the consent of a surviving spouse, parent, a person appointed by you in writing, or your legally authorized representative, for a period of 50 years
  following your death.
- National Security and Intelligence Activities: We will release medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities only as required by law or with your written consent.
- Protective Services for the President and Others: We will disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or conduct special investigations only as required by law or with your written consent.
- Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we will release medical information about you to the correctional institution or law enforcement official only as required by law or with your written consent.
- Psychotherapy Notes: RMIA will not use or disclose psychotherapy notes without your written consent.
- Marketing and Sale of Private Medical Information: RMIA will not use or disclose your private medical information for marketing purposes, nor will RMIA sell your private medical information for marketing purposes without your written consent.
- Breach Notification: You will be notified in writing by RMIA within 60 days if we become aware of any violation of HIPAA privacy rules resulting in the acquisition, unauthorized access, or use or disclosure of your private medical information if that information is not protected by government approved security measures.
You have the following rights regarding medical information we maintain about you:
- Right to Access, Inspect and Copy: You have the right to access, inspect and receive a copy of your medical information that is used to make decisions about your care. Usually, this includes medical and billing records maintained by RMIA.
  If you wish to inspect and copy medical information, you must submit your request in writing to the Medical Records Department. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request, to the extent permitted by
  state and federal law. If we maintain your health information in an electronic health record, you have the right to receive a copy of your health information in electronic form. You may also direct us to provide such electronic health information directly to an entity or person clearly and specifically designated by you in writing. We may deny your request to inspect and copy your information in certain very limited circumstances. For example, we may deny access if your physician believes it will be harmful to your health, or could cause a threat to others. In these cases, we may supply the information to a
  third party who may release the information to you. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by RMIA will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.
- Right to Request Amendment: If you believe that medical information we have about you is incorrect or incomplete, you have the right to ask us to change the information. You have the right to request an amendment for as long as the information is kept by or for RMIA.
To request a change to your information, your request must be made in writing and submitted to the Medical Records Department. In addition, you must provide a reason that supports your request.

RMIA may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
- Was not created by RMIA, unless the person or entity that created the information is no longer available to make the amendment;
- Is not part of the medical information kept by or for RMIA; Is not part of the information which you would be permitted to inspect and copy; or
- Is accurate and complete.
- Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. This list will not include disclosures for treatment, payment, and health care operations; disclosures that you
  have authorized or that have been made to you; disclosures for facility directories; disclosures for national security or intelligence purposes; disclosures to correctional institutions or law enforcement with custody of you; disclosures that took place before April 14, 2003; and certain other disclosures.
To request this list of disclosures, you must submit your request in writing to the Medical Records Department. Your request must state a time period for which you would like the accounting. The accounting period may not go back further than six years from the date of the request, and it may not include dates before April 14, 2003. You may receive one free accounting in any 12-month period. We will charge you for additional requests.
- Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you. If you pay out-of-pocket in full for an item or service, then you may request that we not disclose information pertaining solely to such item or service to your health plan for purposes of payment or health care operations. We are required to agree with such a request. However, we are not required to agree to any other request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
To request restrictions, you must make your request in writing to the Medical Records Department. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, if you want to prohibit disclosures to your spouse.
- Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only at work or only by mail.
To request confidential communications, you must make your request in writing to the Medical Records Department. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted, and we may require you to provide information about how payment will be handled.
- Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this notice. You may ask us to give you a copy of this notice any time. This notice is on our website – www.rmia.com under Contact.
Changes to This Notice

The effective date of this notice is April 14, 2003, and it has been updated effective November 4, 2020. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. If the terms of this notice are changed, RMIA will provide you with a revised notice upon request, and we will post the revised notice on our website – www.rmia.com – and in designated locations at RMIA practice locations.

Complaints or Questions
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with RMIA, or to ask a question about this Notice, contact:
Privacy Officer
2101 Woodwinds Drive, #101
Woodbury, MN 55125
651-222-6050

All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information
Except as described above, RMIA will not use or disclose your protected health information without a specific written authorization from you. If you provide us with this written authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent we have already relied on your authorization. We are unable to take back any disclosures we have already made with your permission, and we are required to retain our records of the care that we provided to you.

Acknowledgement of Receipt of Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. These rights are more fully described in RMIA’s Notice of Privacy Practices. RMIA is permitted to revise its Notice of Privacy Practices at any time. We will provide you with a copy of the revised Notice of Privacy Practices upon your request.

By signing below, you are acknowledging that you have received a copy of RMIA’s Notice of Privacy Practices.
Patient Name

First NameLast Name
Patient Signature

Clear
Patient Email
example@example.com
Date

MonthDayYear
Date
Should be Empty:

Contact Preference and HIPAA Consent to Leave Messages

Email Consent Form

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

NOTICE OF PRIVACY PRACTICES

Acknowledgement of Receipt of Notice