1. finance
2. bank

Dear Client:
Long-term storage of semen specimens through our OverNite MaleTM Program is a
relatively easy procedure for men who are unable to make a personal visit to our facility
to produce a specimen on-site. The enclosed brochure and transport instructions give a
full explanation of our program.
The University Andrology Laboratory, on the campus of the University of Illinois at
Chicago is HCFA (Health Care Finance Administration) approved, CAP (College of
Pathologists) certified, registered and inspected by the FDA (Food and Drug
Administration) and meets all CLIA (Clinical Laboratory Improvement ACT) regulations.
The Director, Gail S. Prins, PhD, is certified by the ABB (American Board of Bioanalysis)
as a High Complexity Laboratory Director (HCLD) and a member of the AATB (American
Association of Tissue Banks).
Thank you for giving us the opportunity to serve you. Our goal is to maintain the highest
standards of care and excellence to our clients with a comprehensive and ethically
responsible sperm banking service.
Thank you,
University Andrology Lab
Patient Banking Program
The University of Illinois
OverNite MaleTM Fee Schedule *
OverNite MaleTM Kit and FedEx Charges (Specimen Conveyance).......... $
75.00
Sperm Cryopreservation........................................................................... $ 150.00
Total Specimen Charge............................................................................. $ 225.00
Annual Storage Fee/Patient....................................................................... $ 275.00
* Prices subject to change
labfee/14
OverNite MaleTM
SEMEN TRANSPORT INSTRUCTIONS
Shipment of semen specimens to the University Andrology Laboratory is possible with the use of OverNite
Male. Semen samples are protected during shipment by a special buffer media. This process ensures the
safe delivery of your specimen to our laboratory for cryopreservation. If the kit is to be used the same
day as kit arrival, follow the instructions located in the kit. If the kit will be used at a later date, store the
buffer bottle in the refrigerator until the day of use, follow the detailed instruction sheet located in the
kit.
The method of shipment is the most important part of this process. We recommend FedEx “Priority
Overnight” as the fastest and safest method available. We have enclosed the proper paperwork for FedEx
shipment which only needs the completion of your part to ensure delivery by 10:30 AM the next day. The
FedEx priority overnight customer service number is 1-800-463-3339. Please remember that our
laboratory is open Monday - Friday with delivery before 10:30 AM. There can be NO Saturday or Sunday
deliveries. This means you can only ship Monday - Thursday, no Friday shipment. Always arrange for
overnight delivery service as time is of great importance for the best cryopreservation of your specimen.
Please notify our laboratory by telephone at least 24 hours in advance of shipment: 312/996-7713. Give
the laboratory the Priority Overnight Air bill Tracking Number located on the enclosed FedEx form so that
we can track the package. This will ensure that our laboratory will be prepared to process your specimen
immediately upon arrival. Along with the first OverNite MaleTM Semen Transport Kit, a two-pocket folder
will be sent with registration and agreement forms which need to be completed by the depositor and
returned with your first shipment to the laboratory. You may contact the University Andrology
Laboratory for results the same afternoon of the arrival of your shipment.
We assume no liability for lost or delayed shipments or for specimens which are shipped by any other
method than that previously described. The charge per specimen for OverNite MaleTM Kit and the FedEx
charges is $75.00 in addition to the standard processing fee of $150.00 per specimen shipped. The
Annual Storage Fee is $275.00 per year no matter how many specimens you have stored in our banking
program. This is an annual charge with the receipt of the first specimen which will ben be charged every
year.
In summary:
1.
2.
3.
4.
5.
Contact the FedEx provider at the 800 number above 1-2 days prior to the expected date of
shipment to find the best method of shipment (FedEx Station or drop-off box). Please note that
due to unpredictable weather conditions, we strongly recommend delivering the package to a
staffed FedEx location or using a drop-off box which is inside a building.
Contact the University Andrology Laboratory (312/996-7713) to inform them of your intent to
ship a specimen and give the Air bill Tracking Number.
Complete the necessary forms to be enclosed with the first specimen (Envelope provided).
Obtain and prepare the specimen for shipment (instructions in the Bio Hazard bag).
Make the necessary arrangements for dropping the package off at a FedEx station or local dropoff box.
If you have any questions regarding any of the above information, please contact our banking coordinator
at 312/996-7713. All questions will be answered in a complete confidential manner. Thank you again for
giving us the opportunity to serve you.
onm/14
Although infectious disease testing is not required if your semen specimens are to be
used by a sexually intimate partner, we recommend testing for HIV 1 and 2 (Aids),
Hepatitis B and Hepatitis C at the time of sperm banking.
If you had any of this testing done recently, please fax or mail a copy of these results to
our Banking Coordinator. Fax to (312) 996-1291.
Rapid Screening Centers offer this testing at many location: (866) 873-0879.
They use LabCorp for testing, which is a CLIA licensed and FDA approved clinical lab
service.
[Directed (known) donors must follow FDA eligibility requirements which can be found
our website: www.uicandrology.com]
If you have any questions, please contact the Andrology Banking Coordinator at:
(312) 996-7713.
Thank you,
University Andrology Lab
Patient Banking Program
The University of Illinois
INSTRUCTIONS FOR BANKING FORMS
The enclosed information is important with regard to
banking your specimens at the University Andrology
Laboratory at the University of Illinois. Our goal
is to maintain the highest standard of care and
excellence to you with a comprehensive and ethically
responsible sperm banking service.
Enclosed you will find the following forms to prepare your chart:
1. Patient Record Form: needs to be fully completed and returned (Please Print)
2. Storage Agreement: needs to be completed, signed by you and returned: second copy is
for your records.
3. Ownership of Sperm Form: gives you two options in the event of your death; I) to destroy
the specimens or II) to relinquish ownership rights to someone else. If designee is not a
sexually intimate partner, directed donor testing must be undertaken (See instructions).
Please be sure to indicate that designated person, their relationship to you along with their
name and signature of that person who will be responsible for your vials. Your signature is
also required. Please note
4. Credit Card Voucher: needs to be completed and returned giving the Laboratory permission
to use your credit card for all services incurred.
For each specimen produced, you will be charged $ 150.00 for processing and freezing. The Annual
Storage fee is currently $ 275.00/year no matter how many vials you have stored with us.
Thank you for giving us the opportunity to serve you. If you have any further questions, please feel free
to contact the Andrology Coordinator, Martha Gasca, at 312/996-7713.
The University Andrology Laboratory
Rev 11/14
University Andrology Laboratory/Banking Program
Patient Record
Patient Name
Date
Home Address
Apt/Floor
City
Home Phone
State
(
)
Cell Phone
E-Mail Address
(
)
Drivers Lic#
Birthdate
Marital Status
Zip
-
SSN
Married
Single
Divorced l
Widowed
Spouse’s
Name
Phone
Number
Employer
Occupation
Work Address
Phone
City
(
)
State
Zip
Name of Friend/Relative (Other than Spouse that does not live with you) WHO WILL ALWAYS KNOW WHERE TO REACH YOU:
Name
Relationship
Home Address
Phone
How did you hear about our program?
Doctor Referral
Relative/Friend
Radio/TV
(
Website
)
Magazine/Newspaper
Referring Physician
Dept.
Address
Suite /Floor
City
Office Phone
Other
State
(
)
Fax
Have you previously used our Banking Services?
(
Zip
)
If Yes - When
NO
List any surgery or other treatment you have had so far:
List any surgery or other treatment you will be having:
Reason for Banking:
Infertility
Cancer Therapy - Type of Cancer:
Surgery - Type of Surgery:
Other:
Directed Donor
Donor Vials
Pre-Vasectomy
Testicular Sperm Extraction
UNIVERSITY OF ILLINOIS
DEPARTMENT OF UROLOGY
UNIVERSITY ANDROLOGY LABORATORY
SPERM BANK STORAGE AGREEMENT
THIS AGREEMENT is made on_________________ 20______, by and between
___________________________________________________, (hereinafter referred to as
“Depositor”), and The University Andrology Laboratory, located at the University of Illinois
College of Medicine, (hereinafter referred to as “Lab”).
WHEREAS, Depositor has been fully advised and understands that there are certain
inherent risks in the process of freezing and thawing semen samples, including, but not limited
to damage to the sperm, reduced capacity for fertilization, and reduced life span of sperm after
thawing, all of these risks he assumes; and
WHEREAS, the parties agree that Lab shall store Depositor’s semen for possible use by
Depositor in the future.
NOW, THEREFORE, the parties mutually agree as follows:
1. Services. Depositor shall provide samples of his semen for collection, identification,
and storage by Lab. Depositor shall follow Lab recommendations regarding
collection process. At the time the first specimen is received by Lab, a complete
semen analysis will be performed by Lab to determine fertility potential. Where the
semen analysis shows that sperm quality is unsatisfactory, Lab shall inform
Depositor prior to permanent storage.
Lab shall freeze and store vials of Depositor’s semen in the number of vials necessary to
contain semen volume.
2. Term. The storage of semen samples shall be from year to year. This agreement
shall automatically renew for an additional one-year period at the end of each year
unless terminated pursuant to the provisions of paragraph 5.
3. Fees. Depositor agrees to pay the processing and storage fees as outlined in the Fee
Schedule in current brochure. In the event that Depositor decides not to continue
with sperm storage after he is informed of the results of semen analysis, then the
Depositor shall pay only the processing fee associated with that analysis.
The annual storage fee may change periodically. Lab shall give written notice in the
form of an invoice mailed by the university to Depositor of the storage charge for the
forthcoming annual period prior to the expiration of each annual period. Depositor shall pay
this annual storage charge within 30 days of the date of the invoice. Failure to submit payment
for the annual storage charge will result in your account being turned over to a collection
agency and vials destroyed.
Page 1 of 3
SPERM BANK STORAGE AGREEMENT
It is Depositor’s responsibility to notify Lab of address and/or telephone number
changes during the term of this agreement. Failure to do so may result in the inability of Lab to
notify Depositor of Annual payment charges, and consequently, may result in disposal of
specimens.
4. Release of Specimen(s). Lab shall release the vials of Depositor’s semen specimens
only upon receipt of express written authorization of Depositor. The conditions and
procedures for release shall be those reasonably established by the Lab.
5. Termination. This agreement shall terminate, and Lab’s responsibility for storage
shall cease, upon the happening of any one or more of the following events:
a. Release of the semen by Lab pursuant to the written authorization of
Depositor.
b. Written direction of Depositor directly to Lab authorizing destruction of all
specimens then presently stored for Depositor
c. Failure of Depositor to notify Lab of change of address and telephone
number as described in paragraph 3.
Notwithstanding any other provisions of the Agreement, either party may terminate this
Agreement upon 30 days written notice to the other party. In the event the notice of
termination is given by Depositor, the storage fees for the then current year shall be deemed
totally earned by Lab. In the event such notice is given by Lab, any unused portion of the
annual storage charge for the then current year shall be prorated on the basis of a 12-month
period, and refunded upon release of the Depositor’s specimens stored by Lab. It shall be the
Depositor’s obligation to arrange for transfer, use, or disposition of the specimens in the event
of a termination of this Agreement for any reason other than Depositor’s death or failure to pay
storage charges. Lab shall exercise it reasonable best efforts to cooperate with Depositor in the
transfer and release of the specimens.
6. Disclaimer and Indemnification. It is specifically acknowledged and agreed by the
between the parties to this Agreement that there is an inherent risk in the process
of collection, freezing, storage, and thawing of semen which may render it
ineffective for insemination purposes, and that Depositor expressly agrees to
assume this risk. It is further agreed that in the event of loss or destruction of the
semen by any reason whatsoever, damages to the client Depositor as a result
thereof would be highly conjectural and speculative and would be difficult to
determine. Accordingly, the parties hereto agree that in the event Depositor’s
semen is lost or destroyed by virtue of the breach of this Agreement or negligence
by Lab, Depositor shall be entitled to liquidation damages in the amount equal to
the annual storage charges for the particular year in which the loss occurs.
Page 2 of 3
SPERM BANK STORAGE AGREEMENT
Depositor further agrees to indemnify, hold harmless, and provide defense from any
claim, demand, or cause of action for damages or otherwise asserted against Lab arising out of
the collection, freezing, storage, or release of Depositor’s semen. The provisions of this
paragraph shall extend to and include the Lab, its officers, directors, employees, and agents.
7. Notices. Any notices to either party to the Agreement shall be sent to the address
set forth beneath the party’s signature to the Agreement, or such other address as
the party may request in writing be used for that purpose. Depositor acknowledges
that it is his obligation to provide his correct mailing address in writing to Lab at all
times during the terms of the Agreement, and any extensions thereof.
8. Entire Agreement. This Agreement represents the entire agreement between the
parties concerning the subject matter; and there are no understandings,
agreements, or representations other than as therein set forth. This Agreement
shall be construed in accordance with the laws of Illinois.
IN WITNESS WHEREOF, the parties have duly executed this Agreement on the day and
year first above written.
University Andrology Laboratory
University of Illinois
Depositor: Signature Required
By:____________________________
By:______________________________
Address: 840 S. Wood St.
Address:__________________________
Chicago, IL 60612
_________________________________
(312) 996-7713
_________________________________
Rev. 04/12
Page 3 of 3
Department of Urology (MC 955)
University of Andrology Laboratory
840 South Wood Street
Chicago, IL 60612-7316
Phone: 312-996-7713
Fax: 312-996-1291
Ownership of Cryopreserved Sperm
Sperm Banker’s Name:
www.uicandrology.com
____________________________________________
Please Print
Gail S. Prins, PhD, HCLD
Director
Choose option 1 or 2 in the event of your death:
1)
Destroy my specimen(s) upon my death.
Print Sperm Banker’s Name
2)
Signature
Date
Upon my death, I give ownership rights** to:
Print Designee’s Name
Designee’s Signature
Designee’s Phone #
Designee’s Address
Sperm Banker’s Signature
(Relationship)
Date
**If designee is not a sexually intimate partner, directed donor testing must be done. (See instructions).
If, at any time, you wish to give permission to someone to make withdrawals of your sperm vials
(i.e. spouse/partner, parent, sibling), please indicate below.
Print Designee’s Name
Designee’s Signature
Designee’s Phone #
Designee’s Address
Sperm Banker’s Signature
(Relationship)
Date
If you do not return this signed form, the laboratory cannot legally release your specimens to anyone other than you.
Please return form to:
09/2014
University Andrology Laboratory
University of Illinois - M/C 955
840 South Wood Street
Chicago, IL 60612-7316
UNIVERSITY ANDROLOGY LABORATORY
CREDIT CARD VOUCHER
All charges will be applied to your credit card after
the processing and freezing of your specimen (s).
This will also include your Annual Storage fee and
kit(s) that are sent to you for the production of your
specimen (s). Please complete the bottom portion of
this form and fax this form to the Banking Program
at 312/996-1291.
I, ___________________________________ give the University Andrology Laboratory/Sperm
Banking Program, permission to use my credit card below for any incurred charges relating to
the freezing of my or Mr._________________________________________________ semen.
Please charge my:
Visa MasterCard  Discover Amer Exp
(Please check one)
Name on Card:
_________________________________________________
Credit Card Number: _________________________________________________
Expiration Date:
_______________________________________
3 or 4 digit Security Code:
Signature:

Rev. 04/12
___________________ (On back of card/front of card for Amex)
______________________________________________
Please check box if receipt is needed for insurance purposes.