Internal Form: Match Sheet

Embryo Donor Match
Clinic/Physician
Embryo Donor 1
First NameLast Name
Date of Birth
MonthDayYear
1
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Email
Embryo Donor 2
First NameLast Name
Date of Birth
MonthDayYear
2
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Email
Relationship status
Embryo Recipient 1
First NameLast Name
Date of Birth
MonthDayYear
3
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Email
Relationship status
Embryo Recipient 2
First NameLast Name
Date of Birth
MonthDayYear
4
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Email
Relationship status

I authorize EM•POWER with Moxi to exchange information and obtain necessary documents pertaining to my embryo donation with/from the following parties, including but not limited to medical records, legal contracts/consents/clearances, third party records (such as egg/sperm donor profiles) with the following parties:
Clinic
Clinic
Embryo storage facility
Consultant Embryologist
Embryo shipping
FDA testing lab
Surrogacy agency
Egg donor agency/bank
Sperm donor agency/bank
Attorney representing Embryo Donor(s)
Attorney representing Embryo Recipient(s)
Mental health professional for Embryo Donor(s)
Mental health professional for Embryo Recipient(s)
Mental health professional for Joint Session
Genetic counselor for case
EM•POWER case manager
NOTICE:
Organizations such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
YOUR RIGHTS:
This authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity’s obligation to pay a claim, or (4) to create health information to provide to a third party.
This authorization may be revoked at any time. The revocation must be in writing and signed by you or your patient representative. The revocation will take effect when we receive it.
You are entitled to receive a copy of this authorization.
Duration: This authorization is valid for one year from the date of the signing unless revoked in writing by the undersigned within one year.
Documents to be shared with and by:
Name of organization: EM•POWER with Moxi
Contact: Gina Davis
Address: PO Box 82641 Portland, OR 97282
Phone: 503-837-1810
Fax: 415-942-5939
Email: gina@empowerwithmoxi.com
Electronic documents requested. Please alert us if you send documents by mail.
Embryo Recipient #1 Signature: BY SIGNING HERE, I AM AGREEING THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Embryo Recipient #2 Signature: BY SIGNING HERE, I AM AGREEING THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Embryo Donor #1 Signature: BY SIGNING HERE, I AM AGREEING THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Embryo Donor #2 Signature: BY SIGNING HERE, I AM AGREEING THAT I HAVE READ, UNDERSTAND AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
DONOR IDENTITY DISCLOSURE DECLARATION
I consent to the disclosure of my full name, date of birth, and contact information to the recipients of my donated embryos now, and to donor-conceived person(s) in the future. I consent to the release of relevant medical, genetic, and family history information that is collected as part of the journey management process to the recipients of my donation, and to donor-conceived person(s) in the future.
Embryo Donor #1 Signature: BY SIGNING HERE, I AFFIRM THAT I CONSENT TO THE DISCLOSURE OF MY FULL NAME, DATE OF BIRTH, AND CONTACT INFORMATION TO THE RECIPIENT(S) OF MY DONATED EMBRYOS NOW, AND TO DONOR-CONCEIVED PERSON(S) IN THE FUTURE. I CONSENT TO THE RELEASE OF RELEVANT MEDICAL, GENETIC, AND FAMILY HISTORY INFORMATION THAT IS COLLECTED AS PART OF THE JOURNEY MANAGEMENT PROCESS TO THE RECIPIENT(S) OF MY DONATED EMBRYOS, AND TO DONOR-CONCEIVED PERSON(S) IN THE FUTURE.
Embryo Donor #2 Signature: BY SIGNING HERE, I AFFIRM THAT I CONSENT TO THE DISCLOSURE OF MY FULL NAME, DATE OF BIRTH, AND CONTACT INFORMATION TO THE RECIPIENT(S) OF MY DONATED EMBRYOS NOW, AND TO DONOR-CONCEIVED PERSON(S) IN THE FUTURE. I CONSENT TO THE RELEASE OF RELEVANT MEDICAL, GENETIC, AND FAMILY HISTORY INFORMATION THAT IS COLLECTED AS PART OF THE JOURNEY MANAGEMENT PROCESS TO THE RECIPIENT(S) OF MY DONATED EMBRYOS, AND TO DONOR-CONCEIVED PERSON(S) IN THE FUTURE.
Communication preferences
Egg source
Sperm source
Embryo(s) to be donated:
Egg donor used?*
YesNo
Sperm donor used?*
YesNo
Clinic where embryos were created
Were embryos created after January 1, 2025?*
YesNo
Address of clinic (where embryos were created)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Clinic phone number (where embryos were created)
Please enter a valid phone number.
Coordinator, doctor, or embryologist clinic email address (where embryos were created)
example@example.com
Colorado license number of clinic where embryos were created (if applicable)
Entity for egg donation (agency or bank name)
Address of egg donation agency or bank
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone number for egg donation agency or bank
Please enter a valid phone number.
Email address for contact at egg donation agency or bank
example@example.com
Colorado license number for egg donation agency or bank (if applicable)
Entity for sperm donation (agency or bank name)
Address of sperm donation agency or bank
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone number for sperm donation agency or bank
Please enter a valid phone number.
Email address for contact at sperm donation agency or bank
example@example.com
Colorado license number for sperm donation agency or bank (if applicable)

	Records available	Plan
Donor profile	5
DED	6
Infectious disease testing	7
Medical record, physical exam	8
Risk factor questionnaire	9
Carrier screening records	10
Karyotype	11
Donor consent/contract to re-donate	12

	Records available	Plan
Infectious disease testing	13
Medical record, physical exam	14
Risk factor questionnaire	15
Carrier screening records	16
Karyotype	17

	Records available	Details
HIV 1/2	18
Hep B	19
Hep C	20
Syphilis (RPR, VDRL, Treponemal)	21
Gonorrhea	22
Chlamydia	23
WNV (after 2016, and not mandated for autologous use)	24
HTLV 1/2 (may not be available if no risk factors present)	25
Zika (based on timing and geographic exposure)	26
CMV (complicated, likely available for anonymous sperm donors; may be available for anonymous egg donors; unlikely available for autologous cases)	27

	Records available	Plan
Donor profile	28
DED	29
Infectious disease testing	30
Medical record, physical exam	31
Risk factor questionnaire	32
Carrier screening records	33
Karyotype	34
Donor consent/contract to re-donate	35

	Records available	Plan
Infectious disease testing	36
Medical record, physical exam	37
Risk factor questionnaire	38
Carrier screening records	39
Karyotype	40

	Records available	Details
HIV 1/2	41
Hep B	42
Hep C	43
Syphilis (RPR, VDRL, Treponemal)	44
Gonorrhea	45
Chlamydia	46
WNV (after 2016, and not mandated for autologous use)	47
HTLV 1/2 (may not be available if no risk factors present)	48
Zika (based on timing and geographic exposure)	49
CMV (complicated, likely available for anonymous sperm donors; may be available for anonymous egg donors; unlikely available for autologous cases)	50

	Records available	Plan
Embryology report	51
Retrieval records	52
PGT results	53
Thaw protocol	54
Vitrification protocol	55
Grading protocol	56

	Records available	Plan
Embryology report	57
Retrieval records	58
Thaw protocol	59
Vitrification protocol	60
Grading protocol	61

Gamete Providers Summary
Egg Sperm
Gamete Provider
Tissue Type at Collection
Age at Gamete Collection
Ancestry/Ethnicity
Genetic Testing History
Genetic Risk Assessment
FDA Donor Screening & Testing
Embryo Donation Protocol Summary
Embryo Donor(s)
Embryo owner(s) name(s)
Donation Type
Genetic Risk Assessment
Mental Health Consultations
Legal Clearance
Recipients Summary
Recipient 1 Recipient 2
Name
Genetic Counseling Match Consultation
FDA Recipient Counseling
Mental Health Consultations
Legal Clearance

	Embryo Donor(s)
Embryo owner(s) name(s)
Donation Type
Genetic Risk Assessment
Mental Health Consultations
Legal Clearance

Included documentation

	Documentation details
Match sheet
Release of information consent (Donors)
Release of information consent (Recipients)
Clinic specific requests
Thaw protocol
Cryopreservation report
Embryology report
Andrology lab worksheet
PGT-A results
Sperm source infectious disease results
Sperm source genetic carrier screening results
Egg source infectious disease results
Egg source genetic carrier screening results
Genetic risk assessment
Genetic match consultation
Mental health consultation: donor(s)
Mental health consultation: recipient(s)
Mental health consultation: joint
Legal clearance letter: donor(s)
Legal clearance letter: recipient(s)
Other

Included Documentation
Comments
Should be Empty:

	Egg	Sperm
Gamete Provider
Tissue Type at Collection
Age at Gamete Collection
Ancestry/Ethnicity
Genetic Testing History
Genetic Risk Assessment
FDA Donor Screening & Testing

	Recipient 1	Recipient 2
Name
Genetic Counseling Match Consultation
FDA Recipient Counseling
Mental Health Consultations
Legal Clearance

Embryo Donor Match