Conceptual Options Surrogacy Program

PAYMENT/REIMBURSEMENT REQUEST

Conceptual Options' Agency Protocol requires that all Surrogate's shall submit all requests for payment and/or reimbursement for items listed in the surrogacy contract no later than 15 days before the payment is due. Funds are paid out of expense accounts on the 1st of every month, unless your contract stipulates otherwise. In the event that requests are not received by the 15th, your payment may be delayed.*
*MUST submit monthly form before 15th current month"

*** If you have RX reimbursements, health insurance premiums, life insurance or copy reimbursements medical bills you must fax, email or mail them directly to our billing coordinator. Her email address is billing@conceptualoptions.com ***

*Information required below:

Surrogate's Full Name:*

Date of Embryo Transfer* (Real or Scheduled or if Unknown just put "unknown"):

Address Check will be Mailed to:*

If Applicable, Number of Weeks Pregnant on the 1st of the Upcoming Month:*

Email Address:*

Contact Phone Number: * XXX-XXX-XXXX

ITEMS REQUESTED FOR PAYMENT:

Monthly Non-Accountable Expense Allowance: (1st pay after contract notarized by Surro & IPs for following month **contract may vary**)
Amount $:

Identify Paragraph/Section in Contract authorizing this payment:

Monthly Pregnancy Compensation Due: (1st pay after IVF HCG/Heartbeat Confirmation letter for following month **contract may vary**)
Amount $:

Identify Paragraph/Section in Contract authorizing this payment:

Monthly Twin/Triplet Compensation Due: (1st pay after 16th week Pregnant for following month **contract may vary**)
Amount $:

Identify Paragraph/Section in Contract authorizing this payment:

Mileage Reimbursement (round trip): (from prior period to 15th current month - Need MapQuest **contract may vary**)

miles
mile base
cents per mile

Date(s) and purpose for mileage reimbursement requested:

Identify Paragraph/Section in Contract authorizing this payment:

Email Mapquest printout of trip mileage to accounting@conceptualoptions.com

Childcare Reimbursement: (ONLY for bed-rest, from 15th last month to 15th current month - Need receipts/MDO letter **contract may vary**)
Amount $:

Date(s) and purpose for childcare reimbursement requested:

Identify Paragraph/Section in Contract authorizing this payment:

Monthly Counselling Appointment: (for current month - ONLY once monthly **contract may vary**)
Amount $:

Date(s):

Identify Paragraph/Section in Contract authorizing this payment:

Maternity Clothing Allowance Due: (1. Singleton: pay after 14th week)
(2. Twins: 1st pay after 12th week / 2nd pay after 24th week **contract may vary**)
Amount $:

Current # Wks. Pregnant

Identify Paragraph/Section in Contract authorizing this payment:

Embryo Transfer fee or IUI Fee: (pay for current month transfer (ONLY transfer been done) **contract may vary**)
Amount $:

Date of procedure:

Identify Paragraph/Section in Contract authorizing this payment:

Start of Injectable Medications Fee:
Amount $:

Date of Start:

Identify Paragraph/Section in Contract authorizing this payment:

Lost Wages Reason: (ONLY for bed-rest, IVF appts up to 5 days, or after delivery bedrest - Need 3 recent paystubs, or/and MDO letter, or/and EDD statement - **contract may vary**)

Date(s) being Reimbursed:

Hourly Pay: hours per hour

***Note: Wages are paid at Net only (i.e.; less taxes and deductions)
Email 3 pay stubs / Physicians note / EDD to accounting@conceptualoptions.com

Identify Paragraph/Section in Contract authorizing this payment:

Life Insurance Premium: (NOT included in monthly check, will be separately processed)
Amount $:

Identify Paragraph/Section in Contract authorizing this payment:

Housekeeping Needed: (ONLY for 3rd trimester or bed-rest - Need receipts and MDO letter **contract may vary**)

Bedrest Dates:

Reason:

Amount to be Reimbursed for Housekeeping $:

Identify Paragraph/Section in Contract authorizing this payment:

Other Misc. Reimbursements/Funds Requested: (Any other reimbursement and requests, included but not limited: massage, husband lost wages, breast milk, C-section, drop cycle fee - Need receipts or valid documents - **contract may vary**)

Reason:

Amount $:
Date(s) of Occurrence:

Identify Paragraph/Section in Contract authorizing this payment:

Final Payment (Please check this box if this is your final payment)

I, * ,hereby state that the amounts listed on page one and two of this form are due to me according to the contract I have signed with my Intended Parent(s) and that I will email any and all receipts/invoices pertaining to said fees to this form and that I fully understand that all reimbursements are to be approved prior to release of funds. Any funds that are owed as a result of bedrest, disability or medical condition requires a copy of doctor�s note on file. I understand that any missing receipts or late requests may result in a delay or denial of request. My electronic signature below is my valid signature, and is binding.

Note that lost wages beyond 7 days requires submission to State Disability/Employment Development Department for benefits request and that reimbursement is for net lost wages not covered by the State. Claim forms are available through your Obstetricians office.

Please note: the amount(s) listed on this form are subject to review and change.

Signature:*
Date:* MM-DD-YYYY

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