---
title: Surrogacy Medical Clearance Records Request Form Template | Paperform
description: Request medical records for surrogate pregnancy clearance including reproductive health assessments, psychological evaluations, and intended parent coordination. HIPAA-ready template.
url: "https://paperform.co/templates/surrogacy-medical-clearance-records-request-form"
type: static
generatedAt: "2026-03-28T00:45:19.078Z"
---

[← Back to free form templates](/templates/)    ![Surrogacy Medical Clearance Records Request Form](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/surrogacy-medical-clearance-records-request-form.png)
    [Preview](https://_preview.paperform.co/ai-template/surrogacy-medical-clearance-records-request-form) [Use this template for free](/create?ai-template=surrogacy-medical-clearance-records-request-form)    [Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/)[Mental Health](/templates/industry/mental-health/) [Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Psychologist](/templates/role/psychologist/)[Social Worker](/templates/role/social-worker/)[Healthcare Administrator](/templates/role/healthcare-admin/)     About this free form template
### Streamline Your Surrogacy Medical Records Process with Paperform

Navigating the surrogacy journey requires careful coordination between surrogates, intended parents, fertility clinics, and healthcare providers. One critical step in this process is obtaining comprehensive medical records for surrogate clearance—a task that often involves multiple forms, phone calls, and follow-ups across different healthcare facilities.

Our **Surrogacy Medical Clearance Records Request Form** simplifies this essential workflow, helping fertility clinics, surrogacy agencies, reproductive health centers, and intended parents gather all necessary medical documentation in one streamlined process.

#### Why Medical Records Matter in Surrogate Pregnancy Clearance

Before a surrogate can be medically cleared for pregnancy, healthcare providers need a complete picture of her health history. This includes reproductive health assessments, psychological evaluations, previous pregnancy records, and current health status. Missing or incomplete records can delay the matching process and create frustration for everyone involved.

This template is designed specifically for the unique requirements of surrogacy medical clearance, capturing not just basic patient information but also the specific records needed for reproductive health evaluation, psychological readiness assessment, and coordination between surrogates and intended parents.

#### Who Benefits from This Template?

**Fertility Clinics & Reproductive Endocrinologists** can use this form to request records from a surrogate's previous healthcare providers, ensuring they have all necessary information before proceeding with medical screenings and embryo transfer protocols.

**Surrogacy Agencies** can provide this form to prospective surrogates during the application process, making it easier to gather medical histories and coordinate with clinics and intended parents throughout the matching and clearance process.

**Intended Parents** working with independent surrogates can use this template to help their surrogate request records from multiple providers, keeping the process organized and ensuring nothing is overlooked.

**Healthcare Providers** supporting surrogates can use this form to understand exactly what records are needed and where they should be sent, reducing back-and-forth communication and speeding up the clearance timeline.

#### Key Features of This Template

This form captures all the essential information needed for surrogacy medical records requests:

 - **Surrogate contact information and authorization** for records release
 - **Detailed list of required records** including OB/GYN history, pregnancy and delivery records, reproductive health assessments, and psychological evaluations
 - **Intended parents information** for coordination and communication
 - **Provider information** for both sending and receiving records
 - **Specific record date ranges** to ensure relevant historical data is included
 - **Purpose of request** clearly stated for HIPAA compliance
 - **Delivery preferences** for electronic, mail, or fax transmission
 - **Authorization signatures** meeting legal requirements

The form's conditional logic ensures that only relevant questions appear based on the surrogate's history, creating a cleaner experience while still capturing comprehensive information.

#### How Paperform Makes This Process Better

With Paperform's intuitive form builder, you can customize this template to match your clinic's branding, add your logo, and adjust questions to fit your specific protocols. The document-style editor makes it easy to add explanatory text, update field labels, or include additional assessment requirements unique to your practice.

**File uploads** let surrogates attach existing records they may already have on hand, speeding up the process even further. **Conditional logic** shows or hides questions based on previous answers—for example, only asking about cesarean section records if the surrogate has had a C-section.

Once submitted, you can use **Papersign** (papersign.com) to send a formal authorization agreement for electronic signature, creating a legally compliant records release without printing, scanning, or mailing documents. This is particularly valuable for interstate surrogacy arrangements where in-person signatures aren't practical.

#### Automate Your Surrogacy Coordination Workflow

Medical records requests are just one piece of the surrogacy clearance puzzle. With **Stepper** (stepper.io), Paperform's AI-native workflow builder, you can automate what happens after the form is submitted:

 - Send automatic notifications to the surrogate's healthcare providers requesting records
 - Create tasks for your team to follow up on missing documentation
 - Update your CRM or case management system with submission details
 - Send personalized confirmation emails to both the surrogate and intended parents
 - Trigger different workflows based on the types of records requested

This automation reduces manual data entry and ensures no request falls through the cracks during the busy clearance process.

#### Security and Compliance You Can Trust

Medical records contain sensitive protected health information (PHI), and any platform handling this data needs robust security. Paperform is **SOC 2 Type II certified** and offers enterprise-grade security features including data encryption, secure data storage, and granular access controls.

While Paperform is not a HIPAA-compliant solution, this form template can be used as part of your HIPAA-compliant workflow when combined with appropriate administrative, physical, and technical safeguards that your organization has in place. Many fertility clinics and surrogacy agencies use Paperform for initial intake and coordination, then transfer PHI to their HIPAA-compliant electronic health record systems.

#### Integration with Your Existing Systems

Paperform connects seamlessly with the tools you already use. Send form submissions to your practice management software, log requests in Google Sheets for tracking, notify your team via Slack, or sync data to Airtable for case management. With thousands of integration options through Stepper, Zapier, Make, and webhooks, you can build a connected workflow that eliminates duplicate data entry.

#### Get Started in Minutes

This template is ready to use right out of the box, but you can customize every element to fit your specific needs. Adjust the questions, add your clinic's policies and procedures, include cost estimates for records fees, or embed the form directly on your website for a seamless patient experience.

Whether you're a high-volume fertility clinic processing dozens of surrogate applications, a boutique surrogacy agency providing personalized service, or intended parents coordinating an independent journey, this template helps you gather complete, accurate medical information efficiently—so you can focus on supporting surrogates and intended parents through this remarkable process.

Start with this template today and experience how Paperform transforms surrogacy medical records coordination from a time-consuming administrative task into a streamlined, professional workflow.
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