Welcome patients of Kaiser Permanente. Below you will find the forms required to set up a specimen storage account with ReproTech, and at the bottom, the forms needed to have your sperm, embryos or oocytes transferred back to Kaiser Permanente.
 
If you are a patient who will be storing cryopreserved semen, embryos or oocytes, please download and complete the applicable forms indicated below and provide to Kaiser Permanente.
 
Please note that the Specimen Transfer From RTL and Medical Information Release form, at the bottom, is required upon RETURN of your specimens to Kaiser Permanente for ART procedures. This Transfer FROM RTL forms require patient signatures (couples must BOTH sign) in the presence of a Notary Public.
 
We look forward to serving you.
 
Specimen Shipping Liability Protection is available exclusively to ReproTech clients through CNA Financial Corporation, a premier insurance broker in the U.S.
 
Reproductive Tissue – Semen, Testicular Tissue, Oocytes, Ovarian Tissue – New Patients

• English:
  • SINGLE CD – Reproductive Tissue Forms Packet A02
  • COUPLE – Reproductive Tissue Forms Packet A17
  • MINOR – Reproductive Tissue Forms Packet A03
• Spanish:
  • SP-SINGLE CD – Reproductive Tissue Forms Packet – A02-S
  • SP-COUPLE – Reproductive Tissue Forms Packet A17-S
  • SP-MINOR – Reproductive Tissue Forms Packet A03-S

 
Embryo – New Patients

• English:
  • COUPLE – Embryo & Donor Embryo Forms Packet A16
  • SINGLE CD – Embryo & Donor Embryo Forms Packet A01
• Spanish:
  • SP-COUPLE – Embryo & Donor-Embryo Forms Packet A16-S
  • SP-SINGLE CD – Embryo & Donor-Embryo Forms Packet A01-S

 
All Tissues – Transfer FROM ReproTech – Returning to Clinic
These forms must be notarized. If a couple, BOTH patients must sign in the presence of a notary.

• English:
  • Transfer FROM RTL Auth and Medical Data Release T01
• Spanish:
  • SP-Transfer from RTL Auth and Medical Data Release T01-S