Surrogate Benefit Package
Base Fee:
$28,000
a. Disbursements: $2800 each month as long as surrogate is pregnant,
beginning on the first day of the month following confirmation of
pregnancy by ultrasound fetal heartbeat and the balance paid within 2
weeks after birth.
b. Conditions: If surrogate delivers child on or after 34 weeks from the
date of the embryo transfer, all payments listed above shall be made,
even if child is stillborn or does not survive prior to hospital discharge. If
surrogate delivers prior to 34 weeks from the dates of the embryo
transfer and child does not survive prior to hospital discharge, surrogate
is only entitled to compensation received as of the date of delivery, plus
a prorated amount, if any.
Multiples Fee:
$5,000
a. Disbursements: The Surrogate shall receive $1,000 per month,
starting on the first day of the month following the 16th week of
pregnancy and continuing on the same day each month, so long as she is
pregnant with multiple fetuses.
b. Conditions: If surrogate delivers additional child on or after 32 weeks
from the date of the embryo transfer, all payments listed above shall be
made, even if child is stillborn or does not survive prior to hospital
discharge. If surrogate delivers prior to 32 weeks from the dates of the
embryo transfer and child does not survive prior to hospital discharge,
surrogate is only entitled to compensation received as of the date of
delivery, plus a prorated amount, if any.
Embryo Transfer:
$1,000
For each completed embryo transfer procedure. This covers lost wages,
childcare, housekeeping and miscellaneous expenses. Surrogate may also
be entitled to travel expenses and a companion to accompany her.
Monthly Allowance:
$200**
The Surrogate shall receive $200 per month, starting on the first day of
the month after the surrogate clears her medical and psychological
evaluations and shall continue on the same day of each month thereafter
until either: 1) two months after the birth of a child or 2) this Agreement
is terminated, whichever is earlier. Allowance is in lieu of itemized costs
and includes reimbursements for mileage/gas for trips under 75 miles
(round trip), telephone calls, faxes, postage or federal express charges,
childcare for local doctors visits, and miscellaneous expenses such as
pregnancy test kits, non-prescription vitamins, etc.
**If Surrogate is pregnant with multiple fetuses, this non-accountable
monthly expense allowance shall increase by an additional $50.00 per
month (per fetus) in excess of one, and shall continue as long as
Surrogate is pregnant with each additional fetus. Such increase shall
become effective on the first of the month following eighteen weeks
after the embryo transfer.
_____ (Surrogate initials)
Maternity Clothing:
$1,000
Surrogate shall receive $1000 on the first day of the month following the
16th week after embryo transfer. Alternatively, if the Surrogate is
carrying multiples, she shall receive $500 on the first day of the month
following the 12th weeks after embryo transfer and $500 on the first day
of the month following the 16th week after embryo transfer.
Mock Cycle:
$300
The Mock Cycle fee is due to the Surrogate upon completion of the Mock
Cycle. A Mock Cycle is when the surrogate is given medication to prepare
her uterine lining for embryo transfer, but an actual transfer does not
happen. This is done in order to determine whether the endometrial
lining is responding well to the medication the doctor prescribes. The
surrogate is usually told in advance they are doing a Mock Cycle. If the
surrogate responds well to the medication during the mock cycle, then
the actual embryo transfer happens with her following cycle.
Dropped Cycle:
$300
The Surrogate shall receive a dropped cycle fee if the cycle is cancelled
through no fault of the Surrogate.
Start of Injectable Medications (per cycle):
$250
This is a one-time payment (per cycle) on the first of the month following
the start of injectable meds.
Invasive Procedure:
$500 (each)
1. Amniocentesis or CVS (per needle insertion)
2. Abortion or Termination
3. Fetal Reduction (per needle insertion
4. Ectopic pregnancy
5. Miscarriage after 12 weeks of pregnancy or if D&C or D&E required
6. Cervical Cerclage
7. Any procedure requiring Anesthesia (except when part of any other
procedure listed)
Physician Recommended Cesarean Section:
$2,500
This fee does not include lost wages, childcare, spouses lost wages, or
travel or travel expenses (per diem, parking etc.)
Breast Milk (Pumping):
$250 (weekly)
In the event that the surrogate agrees, and the IP requests, the surrogate
shall receive a weekly compensation of $250 to pump breast milk. The IP
would be responsible to pay for supplies and shipping associated with
pumping. The length of time requested to pump milk is typically a 6
week period. IP may request a shorter or longer timeframe, depending
on their preference and the surrogates willingness.
Loss of Reproductive Capabilities:
$variable
The Surrogate shall receive compensation if she suffers loss of her
reproductive functions/organs as follows: Loss of Tubes $2,000 ($1,000
each), loss of Uterus ($2,000), Loss of ovaries $2,000 ($1,000 each),
complete hysterectomy $5,000, as long as such procedure is performed
within 3 months of the delivery.
_____ (Surrogate initials)
Physician Ordered Bed Rest or Restricted Activity:
$variable
a) Housekeeping expenses if Obstetrician/IVF Physician confirms in
writing that Surrogate is unable to perform normal housekeeping
chores. Housekeeping expense shall not exceed $100 per week.
b) Childcare expenses if Obstetrician/IVF Physician confirms in writing
that Surrogate is unable to care for the daily needs of her children.
Childcare expenses shall not exceed $10 per hour, $100 per day,
and up to $500 per week.
Surrogate must provide receipts to verify these actual expenses.
Intended Parents obligations under this section shall not extend beyond 6
weeks after a miscarriage, abortion or vaginal delivery and 8 weeks after
a cesarean section.
Out of County Travel
a) If Surrogate is required to travel further than 75 miles roundtrip
from her home for doctor, clinic and surrogacy related travel,
surrogate shall be reimbursed for all miles in excess of 75 miles
(starting at mile 76) at $.58 per mile. Surrogate shall receive a nonaccountable allowance of $50.00 per day for out of town travel over
8 hours or $25.00 per day for travel between 4 to 8 hours (which
shall not apply to Surrogate if she is in the hospital.)
b) If Surrogate is required to travel by air or stay overnight, Intended
Parents shall pay or reimburse surrogate for airfare, hotel, ground
transportation, parking, Childcare expenses (up to a maximum of
$100 per day), and a non-accountable miscellaneous/meal
allowance ($50 per day). Childcare expenses incurred incident to
travel for an embryo transfer are included within the Embryo
Transfer Fee.
Companion Travel
If Surrogate must travel as a result of the embryo transfer procedure, any
invasive procedure, or the birth, Intended Parents shall pay for the travel
expenses of a companion to accompany the surrogate. Travel expenses
shall be limited to a non-accountable miscellaneous/meal allowance of
$50 per day, ground transportation and airfare. Companion shall share
any lodging accommodations with surrogate.
Life Insurance Policy
$400-600(approx.)
Intended Parents shall pay for the premium of a term life insurance policy
for surrogate. It is the surrogate’s responsibility to apply for a term life
insurance policy of $350,000 typically prior to the first embryo transfer
procedure with the direction and support of the Agency. If the sum is
paid directly by the surrogate, a copy of the check along with the
insurance approval letter must be submitted for reimbursement.
Lost Wages
Surrogate will be entitled to reimbursement of her actual net lost wages
incurred as a result of doctor ordered bed rest and time away from work
due to medical appointments. If Surrogate is ordered to bed rest, then
she must apply for disability, if available. IPs will only pay the Surrogates
actual lost wages – the difference between her lost wages and disability
payments. Surrogate is eligible for lost wages through 6 weeks post
vaginal delivery or 8 weeks post cesarean section delivery. Surrogate is
required to provide the Agency Parents with three of her most recent
paystubs.
_____ (Surrogate initials)
Surrogate Lost Wages (To be confirmed and signed by the Surrogate)
I, certify I AM CURRENTLY WORKING and am entitled to Lost Wages for
medical appointments and physician ordered bed rest after a pregnancy is
achieved – based on NET (after tax) hourly wages and any Intended
Parent(s) will only pay the amount not paid by State Disability Insurance.
I am currently earning $_____ per hour (gross) and understand the
amount agreed to in the contract once finalized will be the amount I am
to receive under this paragraph. (Please submit 2-3 of your most recent
paystubs with this signed agreement)
Surrogate’s Signature: ______________________
I, understand I AM NOT CURRENTLY WORKING and am not entitled to
Lost Wages for medical appointments or physician ordered bed rest after
a pregnancy is achieved – If I become employed after I have submitted
this form I agree not to ask for reimbursement for lost wages for medical
appointments or in the event I am put on bed rest at anytime throughout
the pregnancy or after delivery.
Surrogate’s Signature: ______________________
Spouse/Companion Lost Wages
Intended Parents shall compensate Surrogate for Husband’s/Companion’s
net Lost Wages (up to 8 hours per day) as follows: (i) for each screening
appointment (maximum 1 day); (ii) for the match meeting with Intended
Parents (maximum 1 day); (iii) the embryo transfer procedure where
surrogate is required to travel out of her county (maximum 3 days); (iv)
invasive procedures (maximum 1 day); and (v) delivery/birth (maximum 2
days). Husband/Companion shall be required to submit up to 3 recent
paystubs.
Psychological Support only as needed
Actual Costs
Intended Parent shall pay the professional charges of a mental health
care professional for up to 15 counseling sessions during the term of this
Agreement and up to two months after a delivery or termination of this
Agreement, if recommended by a mental health care professional or
Agency
PLEASE INITIAL BELOW TO ALL THAT APPLY; IF RESTRICTIONS SHOULD
APPLY, PLEASE BE
SPECIFIC AND SPECIFY CLEARLY ANY RESTRICTED CIRCUMSTANCES
***Special note: Elective abortion for gender (male/female) reasons in
the event of an extraordinary life change/death of the Intended
Parents/or a change of mind about becoming parents ARE NOT
permitted for any reason. All Intended Parents going through this
process are investing a great deal of money and emotional time with
the hope of having a healthy child. Many who receive a
recommendation from their IVF physician to elect to perform embryo
testing on their embryos will genetically test the embryos before
transferring them into their surrogate. However, these options are
not medically recommended to all Intended Parents and although the
situations below rarely occur the surrogates understanding is
essential when answering these important questions.
Amniocentesis: A medical procedure performed during pregnancy to
detect and diagnose genetic abnormalities in a fetus or to test fetal lung
maturity prior to delivery.
CVS testing: A medical procedure performed during pregnancy to detect
and diagnose genetic abnormalities in a fetus, which also identifies
gender and DNA analysis.
Initial here: __________Verifying you are willing to undergo
amniocentesis testing as recommended by the OB physician.
Initial here: ___________Verifying you are willing to undergo CVS testing
as recommended by the OB physician.
PLEASE INITIAL ONLY ONE AREA IN THIS SECTION
Initial here: _________ verifying you are willing to undergo an abortion or
fetal termination for any medical reason.
(Medical reasons are: the surrogates life is at risk if she continues the
pregnancy, the fetus will be stillborn, the fetus is deceased, the fetus
will not live more than one year post birth and/or the OB doctor
recommends an abortion due to genetic/neurological/physical
abnormalities found in the fetus or in the condition of the pregnancy
which will affect the fetus ‘ability to receive proper growth/nutrition
during the pregnancy)
Initial here: __________ if you are willing to undergo an abortion or fetal
termination under restricted medical conditions. Please list each specific
medical condition below in which you would not be willing to undergo an
abortion or fetal termination:
Initial here: _________ if you will not agree to undergo an abortion or
fetal termination for any reason or condition, with the exception of your
own life being at risk.
Selective Reduction: A medical procedure to eliminate one or more fetal
sacs, without eliminating the entire pregnancy; which typically must be
performed prior to the 17th gestational week of pregnancy. This
procedure may be medically advised and recommended in the event of a
multiple pregnancy occurring after the transfer of two (2) or more
embryos, or in the rare event an embryo splits/divides into multiple
embryos or it may be electively preform should a twin or singleton
pregnancy be preferred by the Intended Parents and the surrogate to
protect the health of the pregnancy.
Initial here: _________ verifying you are willing to undergo a selective
reduction procedure to reduce a triplet or greater pregnancy to a
singleton pregnancy.
Initial here: _________ verifying you are willing to undergo a selective
reduction procedure to reduce a triplet or greater pregnancy to a twin
pregnancy.
Initial here: _________ verifying you are willing to undergo a selective
reduction procedure to reduce a fraternal twin pregnancy (fetuses that
are in separate sacs) to a singleton pregnancy.
Initial here: ________Verifying you are willing to undergo a selective
reduction procedure to reduce a triplet pregnancy to a singleton
pregnancy, in the event of an embryo splitting after implantation (Two
(2) embryos are transferred, both implant, and one embryo splits/divides
into identical twins, causing a triplet pregnancy). In this situation the
reduction of the identical twin sac would be advised as this type of
pregnancy is medically considered to be a higher risk for pregnancy and
fetal complications.
Initial here: ________Verifying if you or the Intended Parents preferred a
singleton pregnancy and elected to transfer one (1) embryo the day of
the embryo transfer, but the embryo split/divided resulting in an
identical twin pregnancy and you are willing to continue to carry the
identical twin pregnancy.
Initial here: ________ if you will not agree to undergo a selective
reduction procedure under any circumstances.
Surrogates Initials____________
By signing below I acknowledge that I understand the terms outlined in
this document and that I have agreed to the amounts and terms listed
herein. I agree that I may not changes such terms and amounts in my
contract with Intended Parents.
________________________________________________ ______________
Surrogate’s Signature
Date
** It is the responsibility of the parties to ensure that all terms in the
document are accurately reflected in the surrogacy contract. The
surrogacy contract shall supersede this document.**