Provider Network Interest | PN Testing Agency

The Orchid Provider Network provides secure connection to Egg Donor and Surrogacy Agencies who use the Orchid JMS Software. This network allows you to connect you with more agencies, share information about current cases, request additional details, track internal notes and documents, etc...

By providing the information below, you can ensure the most accurate information will be available for agencies you are working with.

First Name (of contact filling out this form):

Last Name (of contact filling out this form):

Email (of contact filling out this form):

Role (of contact filling out this form):

Do you want your company to be listed on the network as:
* Public - Any agency using Orchid JMS can find this provider by searching or browsing the Network.
* Private - This provider never appears to agencies browsing the Network in Orchid JMS. Any agency that wishes to connect to this provider must manually request to do so.

What do you want your Participation level to be:

* Participating: This provider actively uses the Provider Network application. They can send and receive agency requests, share documents and agencies can share match sheets. In-system and/or email notifications about activity can be customized at the user level (under My Account).

* Passive: This provider can view basic case information, share documents, and receive match sheets but cannot send or receive agency requests. In-system and/or email notifications regarding activity can be customized at the user level (under My Account).

* Unsubscribed: Same as Passive, but provider users will never be sent automated email notifications.

Please provide the following up-to-date information about your company.

What Provider Type most accurately represents your company?

Provider Name:

Branch Name (specific facility name or specific location, if applicable):

License Number (if applicable):

Website:

About:
Provide information about your company and the value you bring to the Assisted Reproductive Technology industry.

General Contact Email:

General Phone Number:

General Fax Number:

Medical Records Contact:

Country:

Street Address:

Street Address 2:

City:

State/Province:

Zip Code:

Timezone:

Please indicate which US States are in your Service Area for this branch.

Provide other information regarding your Service Area, including countries outside the US in which you provide service.

What services does this branch provide?

Adoption

Assisted Reproductive Technology (ART) Law

Billing Management

Carrier's Insurance Review

Case Management

Egg Donation

Egg Freezing

Family Law

Financial Review

Gestational Surrogacy

Health Insurance

Home Visits

In-House Attorney

In-House Escrow

In-House Laboratory

IVF

IVF Monitoring

IVF Ultrasound

Life Insurance

Medical Records Review

Mini IVF

MMPI

NICU - Level I

NICU - Level II

NICU - Level III

NICU - Level IV

PAI

Psychological Screening

Social Worker Screening

Third Party Escrow

Counseling and Support

Other

Please explain.

Do you have additional Branch locations you want listed in the Provider Network?

Branch #2 Information

Branch Name (specific facility name or specific location, if applicable):

License Number (if applicable):

Website:

About:
Provide information about your company and the value you bring to the Assisted Reproductive Technology industry.

General Contact Email:

General Phone Number:

General Fax Number:

Medical Records Contact:

Country:

Street Address:

Street Address 2:

City:

State/Province:

Zip Code:

Timezone:

Please indicate which US States are in your Service Area for this branch.

Provide other information regarding your Service Area, including countries outside the US in which you provide service.

What services does this branch provide?

Adoption

Assisted Reproductive Technology (ART) Law

Billing Management

Carrier's Insurance Review

Case Management

Counseling & Support

Egg Donation

Egg Freezing

Family Law

Financial Review

Gestational Surrogacy

Health Insurance

Home Visits

In-House Attorney

In-House Escrow

In-House Laboratory

IVF

IVF Monitoring

IVF Ultrasound

Life Insurance

Medical Records Review

Mini IVF

MMPI

NICU - Level I

NICU - Level II

NICU - Level III

NICU - Level IV

PAI

Psychological Screening

Social Worker Screening

Third Party Escrow

Do you have another Branch to add?

Branch #3 Information

Branch Name (specific facility name or specific location, if applicable):

License Number (if applicable):

Website:

About:
Provide information about your company and the value you bring to the Assisted Reproductive Technology industry.

General Contact Email:

General Phone Number:

General Fax Number:

Medical Records Contact:

Country:

Street Address:

Street Address 2:

City:

State/Province:

Zip Code:

Timezone:

Please indicate which US States are in your Service Area for this branch.

Provide other information regarding your Service Area, including countries outside the US in which you provide service.

What services does this branch provide?

Adoption

Assisted Reproductive Technology (ART) Law

Billing Management

Carrier's Insurance Review

Case Management

Counseling & Support

Egg Donation

Egg Freezing

Family Law

Financial Review

Gestational Surrogacy

Health Insurance

Home Visits

In-House Attorney

In-House Escrow

In-House Laboratory

IVF

IVF Monitoring

IVF Ultrasound

Life Insurance

Medical Records Review

Mini IVF

MMPI

NICU - Level I

NICU - Level II

NICU - Level III

NICU - Level IV

PAI

Psychological Screening

Social Worker Screening

Third Party Escrow

Do you have another Branch to add?

Branch #4 Information

Branch Name (specific facility name or specific location, if applicable):

License Number (if applicable):

Website:

About:
Provide information about your company and the value you bring to the Assisted Reproductive Technology industry.

General Contact Email:

General Phone Number:

General Fax Number:

Medical Records Contact:

Country:

Street Address:

Street Address 2:

City:

State/Province:

Zip Code:

Timezone:

Please indicate which US States are in your Service Area for this branch.

Provide other information regarding your Service Area, including countries outside the US in which you provide service.

What services does this branch provide?

Adoption

Assisted Reproductive Technology (ART) Law

Billing Management

Carrier's Insurance Review

Case Management

Counseling & Support

Egg Donation

Egg Freezing

Family Law

Financial Review

Gestational Surrogacy

Health Insurance

Home Visits

In-House Attorney

In-House Escrow

In-House Laboratory

IVF

IVF Monitoring

IVF Ultrasound

Life Insurance

Medical Records Review

Mini IVF

MMPI

NICU - Level I

NICU - Level II

NICU - Level III

NICU - Level IV

PAI

Psychological Screening

Social Worker Screening

Third Party Escrow

Do you have another Branch to add?

Branch #5 Information

Branch Name (specific facility name or specific location, if applicable):

License Number (if applicable):

Website:

About:
Provide information about your company and the value you bring to the Assisted Reproductive Technology industry.

General Contact Email:

General Phone Number:

General Fax Number:

Medical Records Contact Information:

Country:

Street Address:

Street Address 2:

City:

State/Province:

Zip Code:

Timezone:

Please indicate which US States are in your Service Area for this branch.

Provide other information regarding your Service Area, including countries outside the US in which you provide service.

What services does this branch provide?

Adoption

Assisted Reproductive Technology (ART) Law

Billing Management

Carrier's Insurance Review

Case Management

Counseling &

Support

Egg Donation

Egg Freezing

Family Law

Financial Review

Gestational Surrogacy

Health Insurance

Home Visits

In-House Attorney

In-House Escrow

In-House Laboratory

IVF

IVF Monitoring

IVF Ultrasound

Life Insurance

Medical Records Review

Mini IVF

MMPI

NICU - Level I

NICU - Level II

NICU - Level III

NICU - Level IV

PAI

Psychological Screening

Social Worker Screening

Third Party Escrow

A total of 5 branches can be added via this form. If you have more than 5 branches, please email us the information at i[email protected] for all branches you would like listed in the Provider Network. Please include the Branch Name, Website, Email, Phone, Fax, Address, Timezone, Service Area, and Services Offered.

A User can login and view connected cases. A Manager User has access to all connected cases and can manage company and user information. A Staff User will only have access to connected cases they are assigned to.

A Contact is a person visible to agencies within your company information, including their name, role, email, and phone number.

A person can be set up as a user, contact, or both.

As the person filling out this form, you will automatically be set up as a Manager User. Would you also like to be listed as a Contact?

Do you have additional Users or Contacts you want set up in the Provider Network?

User/Contact #2

First Name:

Last Name:

Role (job title, position, etc...):

Email:

Phone Number:

License Number (if applicable):

How should this person be set up in the Provider Network?
Select all that apply.

Contact

Manager User

Staff User

Which Branch(es) should this person be connected to?

Do you have another User/Contact to add?

User/Contact #3

First Name:

Last Name:

Role (job title, position, etc...):

Email:

Phone Number:

License Number (if applicable):

How should this person be set up in the Provider Network?
Select all that apply.

Contact

Manager User

Staff User

Which Branch(es) should this person be connected to?

Do you have another User/Contact to add?

User/Contact #4

First Name:

Last Name:

Role (job title, position, etc...):

Email:

Phone Number:

License Number (if applicable):

How should this person be set up in the Provider Network?
Select all that apply.

Contact

Manager User

Staff User

Which Branch(es) should this person be connected to?

Do you have another User/Contact to add?

User/Contact #5

First Name:

Last Name:

Role (job title, position, etc...):

Email:

Phone Number:

License Number (if applicable):

How should this person be set up in the Provider Network?
Select all that apply.

Contact

Manager User

Staff User

Which Branch(es) should this person be connected to?

A total of 5 Users/Contacts can be added via this form. If you would like to add more than 5 at this time, please email us the information at [email protected] for all users/contacts you would like listed in the Provider Network.

Please include the User's/Contact's First and Last Name, Role, Email, and Phone. Also tell us which branches they should be associated with and if they should be set up as a Contact and/or Manager User or Staff User.

Does your company provide IVF Monitoring Services?

Please provide as much of the following information about your monitoring services as possible.

Contact

Point of Contact

Method of Contact

What time do you monitoring hours begin?

What time do you monitoring hours end?

Are you open for monitoring on weekends?

Monitoring Notes

Lab

Do you have an in-house lab?

What other lab should be used?

Pricing

E2 Pricing

P4 Pricing

hCG Pricing

Ultrasound Pricing

Saline Ultrasound Pricing

ERA Pricing

Additional Fees

Pricing Notes

Does your company provide IVF Services?

Please provide as much of the following information about your IVF services as possible.

Should the doctor be copied on Medical Records?

What is your timeline for record review?

Do you have fresh egg donors?

Do you have frozen egg donors?

Do you have an internal surrogacy program?

Is a surrogate's partner required at screening?

Is a cohort meeting required?

GC Age Range Accepted

Max Gestational Age

GC BMI Range Accepted

GC Maximum # of Prior Deliveries

GC Maximum # of Prior C-Sections

Is the Hep B Vaccine required for surrogates?

Is an OB clearance letter required for surrogates?

Is there any other surrogate pre-approval criteria?

Maximum # of Donor Cycles

Donor Age Range Accepted

Is a Pap Smear required?

Is a Genetic Evaluation required?

Recent delivery timeline for medical screening and/or transfer:

Breastfeeding/Pumping timeline for medical screening

IUD/Implanon/Nexplanon Policy

Depo Shot Policy

Birth Control Pill Policy

Tattoo Policy

Covid Vaccine Policy

IVF Liason Notes