Reproductive Medicine & Infertility Associates. I. Reproductive Medicine & Infertility Associates (RMIA)

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1 Reproductive Medicine & Infertility Associates In compliance with the Federal Consumer Credit Protection Act, we wish to notify you of our policies regarding the payment of statements for services rendered on your behalf. Please review the following information regarding our two separate corporations, as there are distinct differences between them in the way payment is collected for services rendered. We want to be certain that you are well informed, so that you are able to have your questions answered prior to having any services performed. I. Reproductive Medicine & Infertility Associates (RMIA) RMIA/General Reproductive Health Center participates with most major insurance carriers and will provide services including (but not limited to): Physician visits/consults Second opinions Ultrasounds Infertility testing (excluding male diagnostic tests, see below) Ovulation induction Inseminations (excluding sperm preparation, see below) Confirmation of pregnancy General surgery done off-site RMIA will verify in advance that coverage exist for services regarding consults, general infertility testing, and treatment. If services are covered, then RMIA will bill the insurance carrier directly. Once the insurance carrier has addressed the claim, RMIA will bill the patient for any remaining financial responsibility. If upon verification of insurance benefits it is known that your insurance does not cover certain services rendered by RMIA, then it is our policy to secure a credit card from the patient to cover the services rendered. If a patient hasn t met his/her financial obligation after a treatment cycle, no further treatment will be conducted until the account has been settled. II. Infertility Laboratory & Surgery Center Associates (ILSCA) (Prices subject to change) ILSCA does not participate with any insurance carriers and will provide services including (but not limited to): In vitro fertilization (IVF) Andrology male diagnostic testing and intrauterine insemination preparations Semen Analysis ($110) Semen Cryopreservation ($400) Sperm Preparations (for intrauterine insemination) Fresh sample ($100) Frozen sample ($100) Sperm and embryo storage fees ($60/month) Surgeries male/female TESE/MESA procedure Office Hysteroscopy ($1,000) Hyperstim Aspiration Payment for all services that fall within the scope of ILSCA is the direct responsibility of the patient, and will be collected in advance. Once services have been provided, then ILSCA will submit a complete HCFA 2016 G:Electronic Documents/181 All Rights Reserved 9/15/16 Page 1 of 4

2 1500 form to the patient s insurance carrier on his/her behalf. The insurance carrier will then communicate directly with each patient regarding any possible reimbursement. Semen Analysis and Semen Cryopreservation: Charges are payable on the day of the specimen collection. You will need to show the lab staff a receipt that verifies payment prior to collecting the specimen. Sperm Preparations (for intrauterine insemination): Charges are payable on the day of the insemination prior to the service being performed. IVF: The full amount of your program fee is collected on the day of your program start. Surgeries: All surgery charges will be collected prior to scheduling the surgical procedure. Sperm cryopreservation is done at the RMIA Woodbury clinic only. * Please note that we do review benefits with patients but we cannot guarantee actual coverage of services. One term you may hear from your insurance carrier is reasonable and customary or the allowed amount. The term reasonable and customary refers to the amount that your health plan determines is the normal range of payment for a specific health related service or medical procedure within a geographical area. If the charges you (or your doctor) submit to your health plan are higher then what the health plan considers normal for the covered service then your health plan may not allow the full amount charged to you. Helpful tips: Call your insurance carrier and see what your coverage is for both in and out of network Once you have the price your physician charges for a given service, call your insurance carrier to find out what they will pay off that service. Some insurance carriers provide this type of information on their website, where customers can use what s called a treatment cost estimator tool Records Release I hereby authorize Reproductive Medicine and Infertility Associates physicians to release to my referring and/or consulting physician, insurance company, spouse, or legal guardian, any information, diagnosis and records of treatment, concerning my medical history and medical care. Assignment of Benefits I/we hereby authorize that payment of any amount due by insurance be paid directly to: Reproductive Medicine and Infertility Associates. Payment is authorized upon receipt of an itemized statement of services. In consideration of services provided, I am agreeing to pay for services provided to me, to my spouse, and to my minor children. I/we agree to pay all charges not covered by insurance. If I/we fail to make payment upon receipt of monthly billing statement my/our account will be turned over to a collection agency. If a suit is necessary to enforce payment of a delinquent account, patients are liable for reasonable attorney s fees incurred by us G:Electronic Documents/181 All Rights Reserved 9/15/16 Page 2 of 4

3 Patient Standard of Care Pledge: Physicians and employees at Reproductive Medicine and Infertility Associates (RMIA) and Infertility laboratory & Surgery Center Associates (ILSCA) hereafter referred to as clinic, are committed to providing the very best care for our patients. The clinic believes that successful patient outcomes require a compliance partnership between the clinic and the patients. Only with this understanding and commitment, is it possible to insure common expectations. With the following standards in place, both patient and the clinic will be assured of consistent and comprehensive process for patient care and treatment. RMIA, and ILSCA will allocate its resources and expertise to patients, and patients agree, to compliance under the following criteria: Patients Agreement to: Keep scheduled appointments or provide advance notice to RMIA under the cancellation policy. Follow through with general infertility testing requirements. Comply with referral and authorization requirements. Follow instructions provided by RMIA staff and/or steps outlined in their treatment plan. Meet financial obligations for services rendered at RMIA. Identify their current primary care and Ob/Gyn physicians who can provide non-infertility services and emergency care. Use after hour telephone service, only for emergency situations as it relates to their care at RMIA. Provide correct demographic and insurance information. Use RMIA educational tools as identified by RMIA staff /website). Follow RMIA policies provided in your new patient packets. Make suggestions for improvement so that RMIA can improve patient satisfaction. Treat all RMIA employees with respect. Follow RMIA s NO cell phone policy Clinic s Agreement to: Professional and supportive care and treatment directed by RMIA Physicians. Credentialed physicians and nurses with the American Society of Reproductive Medicine. Embryology, Andrology, and Endocrine inspected and certified laboratories. State of the art facilities, equipment, and standards of medical services. Provide prompt and courteous service to all of our patients. Multiple options of treatment plans to meet patient needs. Cooperative arrangements with local physicians (in-state and out-of-state) where appropriate to quality care continuity. Protection and confidentiality of health information under HIPAA Guidelines. Member in good standing with national SART, national organization for fertility patient reporting. Be treated with respect from all RMIA employees G:Electronic Documents/181 All Rights Reserved 9/15/16 Page 3 of 4

4 We appreciate the time and financial considerations that are part of our commitment as partners in your care for infertility treatment and we establish these guidelines to care because our experience has shown they increase the opportunity for successful outcomes. We thank you for your understanding and compliance. As in all medical care, the physician may determine transferring care to another provider if it s in the best interest of the patient. PROVIDERS Reproductive Medicine & Infertility Associates Infertility Laboratory and Surgery Center Associates CLIENTS We acknowledge by our signature below that we have read and agreed to the foregoing information regarding the billing practices of the two corporations (RMIA & ILSCA), records release, assignment of benefits, understand that RMIA does not guarantee coverage of services, have had all of our questions answered to our satisfaction, are signing this form voluntarily, and agree to abide by the terms of this document Patient Printed Name ID # Patient signature Date Spouse/Partner Printed Name ID # Spouse/Partner signature Date STUDY PARTICIPATION RECORD ACCESS Reproductive Medicine and Infertility Associates, from time to time, has available patient opportunities to be participants in various studies the clinic may be supporting. I authorize Reproductive Medicine and Infertility Associates to access my medical records to determine eligibility for study participation and to contact me regarding studies. Patient Signature 2016 G:Electronic Documents/181 All Rights Reserved 9/15/16 Page 4 of 4

5 Addendum Cancellation and/or Rescheduling Clause After your program start, an IVF scheduling nurse will discuss possible dates for your cycle monitoring and IVF procedure. The IVF scheduling nurse will schedule dates as promptly as the physician schedule permits. You have the right to accept or decline these dates. However, if declined, RMIA expects a call back in a timely manner with other potential dates. Please note that when we schedule an IVF procedure, we are dedicating a spot and committing time and resources on that particular week for your procedure. There is a limited amount of time slots available each week, and once full, the IVF scheduling nurse will need to look at the physicians schedule to see when the next opening is, probably not until the following month. RMIA is committed to scheduling your IVF dates timely, and expects once the dates are agreed upon, the patient is committed to keeping those dates and will move forward with the IVF procedure. Therefore, for those patients that cancel and/or rescheduled their IVF dates, certain monetary penalties will be charged based on the length of time before cancellation. These charges will need to be paid in full, before any further IVF scheduling. Charges up to the point of cancellation will be assessed on a fee for service basis regardless of the patients IVF program. $200 fee will be assessed to patients who cancel or reschedule > 6 weeks prior to their scheduled TVOR or Frozen Embryo Transfer. $500 fee will be assessed to patients who cancel or reschedule < 6 weeks prior to their scheduled TVOR or Frozen Embryo Transfer. $1,000 fee will be assessed to patients who cancel or reschedule < 2 weeks prior to their scheduled TVOR or Frozen Embryo Transfer. $2,000 fee will be assessed to patients who cancel or reschedule once their HCG medication has been administered and/or who fail to take their HCG. We acknowledge by our signature below that we have read the above and have had all our questions answered to our complete satisfaction. We also agree that RMIA may charge our credit card on file for any cancellation fee that may be incurred. Date: Patient Name (print) Patient Signature Date: Partner Name (print) Partner Signature Credit Card (VISA, MC, Discover, AMEX) Card number: Expiration date: Security code 2016 G:ElectronicDocuments/1648 All Rights Reserved 8/2/16

6 Reproductive Medicine & Infertility Associates PHYSICIAN IDENTIFICATION FORM Reproductive Medicine and Infertility Associates (RMIA) specializes exclusively in the evaluation and treatment of infertility. During the course of your care with us, medical situations may arise which require expertise and facilities more readily available through the office of an obstetrician/gynecologist. Before beginning treatment at RMIA, please designate, and update as necessary, the information requested below. Current demographic information helps assure that your care remains timely and that your insurance benefits and authorizations are current. Primary physician: A physician (usually a family practitioner or internist) you see for general health care; i.e. sore throats, physical examinations, etc. On occasion, a family practice physician may provide uncomplicated or routine obstetrical and gynecological care. OB/GYN physician: A physician who specializes in women s health care- specifically gynecology, pregnancy and their attendant complications. Referring physician: A referral is a formal authorization to see a specialist or subspecialist which may be required by your insurance company. Your referring physician is usually the person designated by you as your primary physician. Depending upon the restrictions of your individual policy, an OB/GYN physician can also be your referring physician. More commonly, your OB/GYN will recommend you visit with us, but can only generate a formal referral to RMIA if he/she has been designated by you as your primary physician. PRIMARY CLINIC PRIMARY PHYSICIAN (first & last name) PRIMARY PHYSICIAN ADDRESS PRIMARY PHYSICIAN PHONE # PRIMARY PHYSICIAN FAX # OB/GYN CLINIC OB/GYN PHYSICIAN (first & last name) OB/GYN CLINIC ADDRESS OB/GYN PHYSICIAN PHONE # OB/GYN PHYSICIAN FAX # REFERRING PHYSICIAN (first & last name) (IF DIFFERENT THAN ABOVE) REFERRING PHYSICIAN ADDRESS REFERRING PHYSICIAN PHONE # REFERRING PHYSICIAN FAX # Printed Name Signature Date Patient Label 2007 All Rights Reserved RMIA MD: G:Electronic Documents/41

7 REPRODUCTIVE MEDICINE AND INFERTILITY ASSOCIATES Woodbury Medical Arts Building 2101 Woodwinds Drive, Suite 100 Woodbury, MN (651) Informed Consent and Authorization for HIV Testing I understand that Reproductive Medicine and Infertility Associates has a policy of testing all patients for HIV. This policy follows the guidelines set forth by the American Society for Reproductive Medicine (ASRM) and was instituted for the protection of both the patient and any resultant offspring conceived through infertility treatment. I. Definition Human Immunodeficiency Virus (HIV) - is the virus that causes AIDS (Acquired Immune Deficiency Syndrome). HIV is spread in the following manner: From an HIV infected mother to her unborn child From an HIV infected mother to her child during breast feeding During unprotected vaginal, anal, or oral sex with an HIV infected person Sharing a needle with an HIV infected person while using intravenous drugs Via blood transfusion prior to 1985 II. Testing A sample of blood will be tested periodically while undergoing treatment at RMIA for signs of HIV infection. If the results of the first test are positive, the patient will be directed to an infectious disease specialist for additional testing. The patient will also work with staff from the Minnesota Department of Health to help notify current or past sexual partners who may be at risk. A negative test result means that no evidence of HIV is found in the blood sample. I understand that every attempt will be made to keep the results of this test confidential. Having been fully informed, I freely and voluntarily sign below: Patient Printed Name Patient Clinic ID # Patient signature Date Partner Printed Name Patient Clinic ID # Partner signature Date PATIENT LABEL PARTNER LABEL 2012 G:ElectronicDocuments/2 All Rights Reserved 4/2/12

8 REPRODUCTIVE MEDICINE AND INFERTILITYASSOCIATES Woodbury Medical Arts Building 2101 Woodwinds Drive, Suite 100 Woodbury, MN (651) PARENTING RESPONSIBILITY AGREEMENT We, the undersigned patient and partner have requested Reproductive Medicine & Infertility Associates (RMIA) to provide certain medical services, as described by separate agreement(s). We understand that during the time that RMIA is providing such services our status could change for a variety of reasons, including, but not limited to, divorce, separation, change in health of the patient, or death. Notwithstanding any change in our status, we, jointly and individually, acknowledge our obligation to support any child or children conceived as a result of the medical services of RMIA. We, jointly and individually, agree that RMIA has no duty or obligation of any kind, including, but not limited to support or other financial obligation, to any child or children conceived as a result of the medical services of RMIA. We freely and voluntarily sign below: Patient Printed Name Patient signature Partner Printed Name Partner signature RMIA Witness Clinic ID Date Clinic ID Date Date PATIENT LABEL 2013 G:ElectronicDocuments/1229 All Rights Reserved 3/11/13

9 CONSENT FORM Patient s Name (printed) DOB Clinic ID number Patient s address EMERGENCY PROBLEMS should never be used for emergency situations. In the event of an emergency, call 911 URGENT PROBLEMS should never be used for urgent situations. In these cases, the patient should call our main number during business hours (M-F 7:30-4:30). After hours you can contact our on call answering service or go to an urgent care. 1. RISKS OF USING TO COMMUNICATE WITH YOUR CLINIC Reproductive Medicine & Infertility Associates referred throughout this consent as Clinic. The Clinic offers patients the opportunity to communicate by . Transmitting patient information by e- mail, however, has a number of risks that patient should consider before using to communicate with the Clinic. These include, but not limited to, the following risks: can be circulated, forwarded, and stored in numerous paper and electronic files sender can type in the wrong address Backup copies of may exist even after the sender or the recipient has deleted his or her copy. Employers have a right to archive and inspect s transmitted through their system. s can be used to introduce viruses into computer systems can be intercepted, altered, forwarded, or used without authorization or detection. s can be used as evidence in court. 2. CONDITIONS FOR THE USE OF Provider will use reasonable means to protect the security and confidentiality of information sent and received. However, because of the risks outlined above, the Clinic cannot guarantee the security and confidentiality of communication and will not be liable for improper disclosure and confidential information that is not caused by the Clinics intentional misconduct. Thus, patient must consents to the use of for patient information. Consent to the use of includes agreement with the following conditions: a) All s concerning diagnosis or treatment will become part of the patients medical records. b) Patient shall not use s for medical emergencies, urgent problems or other sensitive matters. c) If the patient has not received a response back from the Clinic within a reasonable time period, it is the patient s responsibility to follow up to determine whether the intended recipient received the and when the recipient will respond. d) The patient should not use for communication regarding sensitive medical information, such as information regarding, but not limited to laboratory testing, mental health, or health history. e) The patient is responsible for protecting his/her password or other means of access to . The Clinic is not liable for breaches of confidentiality caused by the patient or any third party. f) Clinic shall not engage in communication that is unlawful. g) It is the patient s responsibility to follow up and/or schedule an appointment if warranted G:Electronic Documents/1752 All Rights Reserved 2/3/15 Page 1 of 2

10 3. PATIENT RESPONSIBILITIES AND INSTRUCTIONS To communicate by , the patient shall: a) Limit or avoid use of his/her employer s computer b) Inform Clinic of changes in his/her c) Put the patient s name in the body of the . d) Include the category of the communication in the s subject line e) Review the to make sure it is clear and that all relevant information is provided before sending the . f) Take precautions to preserve the confidentiality of the , such as using screen savers and safeguarding his/her computer password. 4. ALTERNATE FORMS OF COMMUNICATION I understand that I may also communicate with the Clinic via telephone or during a scheduled appointment and that is not a substitute for the care that may be provided during an office visit. Appointment should be made to discuss any new issues as well as sensitive medical information. I also understand that the Clinic also utilizes Notify MD as I go through active treatment and that is also a way to communicate results and changes in my treatment plan. 5. TYPES OF TRANMISSIONS THAT PATIENT AGREES TO SEND AND/OR RECEIVE The types of information that can be communicated by with the Clinic include prescription refills, patient referrals and appointment scheduling reminders and requests, billing and insurance questions, consultation summaries, signed consent forms, IVF treatment plan (calendar) and instructions, and patient education. If you are not sure if the issue you wish to discuss should be included in an , you should call the Clinic to schedule an appointment. If you elect not to provide us with your , but contact us through , we will correspond to any sent to us. In most occasions, you will receive an encrypted via ZixMail. You must provide a username and password to log into ZixMail to retrieve your message(s). The Clinic will be notified of any message not picked up. The Clinic will make one attempt to resend via ZixMail or will mail document(s) to you. If you do not receive our (s), please check your spam or junk mail folder. If you find it there, please identify it as non-junk or non-spam . You may also want to add noreply@rmia.com to your contact or Safe Sender list so that these s do not go to your junk mail folder. 6. SECURITY MEASURES USED BY CLINIC As stated above, communication via does come with privacy risks as stated above. While the Clinic can not guarantee total confidentiality, the Clinic will use reasonable safeguards to protect your health information as required by law. 7. HOLD HARMLESS I agree to hold harmless the Providers, Reproductive Medicine & Infertility Associates, its employees, and website designers against all losses, expenses, damages, costs, including attorney s fees, relating to information loss do to technical failure. The Clinic does not warrant that the functions contained in any material provided will be uninterrupted or error-free, that defects will be corrected, or that the Clinic website or server that makes such site available is free of viruses or other harmful components. PATIENT ACKNOWLEDGEMENT AND AGREEMENT I have discussed with the Clinic representative and we acknowledge that I have read and fully understand the consent form. We understand the risks associated with the communication of between the Clinic and us, and consent to the conditions herein. Date: / / Patient Signature Clinic ID Date: / / Partner Signature Clinic ID 2015 G:Electronic Documents/1752 All Rights Reserved 2/3/15 Page 2 of 2

11 Reproductive Medicine and Infertility Associates IVF Program Criteria Criteria FCWP < 39 FCWP < 35 (100%) or HOPE FCWP using GC FCWP Donor Egg Reg IVF with own eggs Reg IVF with GC Reg IVF with PGD/S Reg IVF with donor egg FET Egg Freezing Age < 39 < 35 < 39 < 51 < 43 < 51 < 40 < 51 < 51 < 40 (Single patients >55 or couples with (Treatment anticipated to (Treatment anticipated to (if using own eggs) (45-50 requires (35-39 considered (45-50 requires a combined age of >110 will be start within 30 days of start within 30 days of clearance from a on a case by case clearance from a excluded. Single patients >50 and couples with a combined age of >100 consent signing) consent signing) perinatologist before basis, and will likely perinatologist before will be considered on a case by case basis) doing any prescreening at RMIA) need 1-2 additional cycles of embryo banking) doing any prescreening at RMIA) BMI (calculate your BMI) 35.0 > 19 and < FSH N/A N/A N/A N/A AMH 1, or normal AMH 1.5, or normal AMH 1, or normal AMH N/A N/A N/A N/A ovarian response ovarian response ovarian response (or AFC) (or AFC) (or AFC) Sperm 100, , ,000 N/A any live sperm any live sperm any live sperm N/A N/A N/A Uterine cavity normal normal normal normal normal normal normal normal normal N/A Previous unsuccessful IVF cycles requires approval from RMIA physician none requires approval from RMIA physician N/A N/A N/A N/A N/A N/A N/A Miscarriages > 2 miscarriages requires approval from RMIA physician. Additional testing may be needed. > 2 miscarriages requires approval from RMIA physician. Additional testing may be needed. > 2 miscarriages requires approval from RMIA physician. Additional testing may be needed. N/A N/A N/A N/A N/A N/A Corrective surgery for: Distal tubal occlusion YES YES N/A YES YES N/A YES YES YES N/A Tubal disease associated with 1 tubal pregnancy 2 tubal pregnancies, irrespective of tubal status Conditions that will predictably decrease success rate: NO NO NO NO NO NO NO NO NO NO Smoking * Some medications Chromosome anomalies and/or PGD need *ALL patients (female and male) must quit all tobacco use (cigarette, cigar, pipe) one month prior to consent signing. Nicorette gum and vaping is permitted. N/A G:ElectonicDocuments/ /29/16

12 PATIENT EDUCATION carrier screening INFORMATION

13 carrier screening AT A GLANCE Why is carrier screening recommended? Carrier screening is one of many tests that can help provide information to you and your doctor about your reproductive risks prior to or during pregnancy. And while most babies are born healthy, with each pregnancy there is a small chance of having a baby with a severe How is carrier screening done? The first step is to determine which disorders you should be screened for based on your ethnic background and family history. Then your doctor will draw one or two tubes of blood to send to the laboratory for testing. It typically takes two weeks for your doctor to get your results. While testing can never eliminate the risk of being a carrier, it does provide the opportunity to explore reproductive options if both partners are carriers for the same disorder. Is carrier screening right for me? Carrier screening can provide you with information that might be helpful if you: Are planning a pregnancy Have a family history of a genetic disorder Are at increased risk for a specific condition based on ethnicity Would like additional information about your reproductive risks Discussing the benefits and limitations of carrier screening with a qualified health care professional, like a genetic counselor, may help you decide if carrier screening is right for you. genetic disorder. Carrier screening helps assess what that chance is for you. What is a carrier? Being a carrier means that one of two copies of a gene has a change, called a mutation, that causes that copy of the gene to stop working properly. Carriers typically do not have any health problems associated with carrying a mutation and often do not know they are carriers until this screening is performed; however, as a carrier, there is a chance that your children could inherit that genetic disorder. Could I be a carrier? Anyone can be a carrier of a genetic disorder, even if no one in your family is affected. The chance of being a carrier is based on your ethnic background and family history; however, some disorders are fairly common regardless of these factors.

14 Why GoodStart Select? The information provided through carrier screening is often used to help guide reproductive decisions, so it is important that the information you and your doctor receive from these tests is not only accurate, but comprehensive as well. Good Start Genetics is a company specializing in carrier screening. GoodStart Select is our customizable test menu, which includes tests doctors often order for common genetic disorders. Your doctor may have recommended GoodStart Select because Good Start Genetics uses a powerful technology called next-generation sequencing. By using this advanced technology, GoodStart Select detects more mutations than other routine carrier screens. This means a higher detection rate and more confidence in your carrier screening test results. At Good Start Genetics, we believe everyone should have access to these important tests. Good Start Genetics has dedicated customer care and billing specialists who will work directly with you to help reduce out-of-pocket expenses for carrier screening. In fact, this type of testing is frequently covered by insurance. Genetic counseling is also available upon request. By using GoodStart Select, you benefit from results you can trust and dedicated customer care throughout your carrier screening experience. For more information about Good Start Genetics, carrier screening, the genetic disorders we test for and our customer care programs, please visit or us at solutions@gsgenetics.com.

15 PAN ETH NIC CARRIER SCREENING FOR common disorders Some genetic disorders are relatively common and carrier screening may be offered to you, regardless of your ethnic background. These disorders are cystic fibrosis (CF), spinal muscular atrophy (SMA), and fragile X syndrome. A brief description of each of these disorders is in the table below. DISORDER CARRIER FREQUENCY SYMPTOMS Cystic Fibrosis (CF) Ashkenazi Jewish: 1 in 23 Caucasian: 1 in 25 Hispanic: 1 in 58 African American: 1 in 61 Asian: 1 in 94 CF is characterized by chronic respiratory and digestive problems. Symptoms and severity of CF range from mild to severe. Intelligence and appearance are not affected. With treatment today, people with severe CF can live into their 30 s. Spinal Muscular Atrophy (SMA) Caucasian: 1 in 47 Asian: 1 in 59 Ashkenazi Jewish: 1 in 67 Hispanic: 1 in 68 African American: 1 in 72 SMA is characterized by severe muscle weakness and progressive loss of voluntary muscle control. Symptoms often begin in early infancy and include difficulties breathing, swallowing, and crawling. Intelligence and appearance are not affected. In severe cases, SMA results in death before two years of age. Fragile X Syndrome All Ethnicities: 1 in 178 women Fragile X syndrome is the most common cause of inherited intellectual disability and is characterized by developmental delay, autism, hyperactivity, and some characteristic physical features. Source: Data on File

16 C ARRIER SCREENING FOR ashkenazi jewish disorders Individuals of Ashkenazi Jewish descent typically have ancestors from Eastern Europe and there are a number of genetic disorders that have an increased frequency in this population. These disorders range in severity and symptoms; however, all of these disorders can have a serious impact on the affected individual s quality of life and often results in an early death. At this time, there are limited or no treatments available for most of these disorders. While these disorders are most common in individuals of Ashkenazi Jewish descent, they may occur in people of other ethnic backgrounds. A list of these disorders is provided here, along with the carrier frequency in individuals of Ashkenazi Jewish descent. DISORDER Bloom s Syndrome Canavan Disease Cystic Fibrosis Dihydrolipoamide Dehydrogenase Deficiency Familial Dysautonomia Familial Hyperinsulinism Fanconi Anemia Group C Gaucher Disease Glycogen Storage Disease Type Ia Joubert Syndrome 2 Maple Syrup Urine Disease Type A/B Mucolipidosis Type IV Nemaline Myopathy Niemann-Pick Disease Type A/B Spinal Muscular Atrophy Tay-Sachs Disease * Usher Syndrome Type IF Usher Syndrome Type III Walker-Warburg Syndrome CARRIER FREQUENCY 1 in in 55 1 in 23 1 in in 31 1 in 68 1 in in 15 1 in 64 1 in 92 1 in 97 1 in 89 1 in in in 67 1 in 27 1 in in in 150 * Screening for Tay-Sachs Disease is also recommended for individuals of Cajun or French Canadian descent. Source: Data on File

17 C ARRIER SCREENING FOR hemoglobinopathies Hemoglobinopathies are a diverse group of disorders characterized by abnormal or decreased production of hemoglobin, a component of blood that carries oxygen throughout your body. The severity of these conditions ranges from mild to severe, depending on the type of hemoglobin defect. The most common hemoglobinopathies (alpha-thalassemia, beta-thalassemia, and sickle cell disease) and the ethnicities in which they are most frequent are outlined in the table below. ETHNICITY ALPHA-THAL BETA-THAL African American Asian Hispanic Non-Hispanic Caribbean Mediterranean Middle Eastern Southeast Asian SICKLE CELL DISEASE rare rare = increased carrier frequency How is carrier screening for hemoglobinopathies done? Two routine blood tests called a complete blood count (CBC) and hemoglobin electrophoresis are the first steps to screening for most hemoglobinopathies. Based on these results, further testing may be needed to find the specific mutations involved.

18 TEST RESULTS AND reproductive options It typically takes one to two weeks to get your carrier screening test results. What does a negative test mean? A negative test means that no mutation was found for the disorder screened. This significantly reduces the chance that you are a carrier of this disorder. However, no carrier screen can detect all possible mutations that could cause disease, so there is always a small chance of being a carrier, even after a negative test; this chance is called residual risk. What does a positive test mean? A positive test means that a mutation was found for the disorder screened and there is an increased chance for you to have a child with this disorder. Even though you are a carrier, you typically will not have any symptoms associated with the disorder. AUTOSOMAL RECESSIVE INHERITANCE unaffected non-carrier 25% carrier father unaffected carriers 50% carrier mother affected individual 25% The next step is to test your reproductive partner. Most likely, they will not be a carrier of the same disorder, in which case the chance to have a child with this disorder is reduced. However, if both you and your partner are carriers of the same disorder, there is a 1 in 4 (or 25%) chance to have a child with that disorder (see diagram of autosomal recessive inheritance). Because the genetics of fragile X syndrome and alpha thalassemia are complex, carriers of these disorders have different reproductive risks than discussed here. If you are a carrier of either of these disorders, talk to your physician and/or a genetic counselor about the next steps for testing and chances to have a child affected with either of these disorders. What if my partner and I are both carriers for the same genetic disorder? There are several reproductive options available for you and your partner. Continue with family planning and pregnancy without prenatal testing Prenatal testing by chorionic villus sampling (CVS) at weeks of pregnancy or amniocentesis at weeks of pregnancy In vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD) prior to pregnancy Egg or sperm donation; screening the donor for the specific high-risk disorder is recommended Adoption is also available to couples who wish to have a child

19 DISORDER Common Disorders Cystic Fibrosis (CF) Spinal Muscular Atrophy (SMA) Fragile X Syndrome** Hemoglobinopathies Alpha-Thalassemia Beta-Thalassemia Sickle Cell Disease Ashkenazi Jewish Disorders Bloom s Syndrome Canavan Disease Familial Dysautonomia Fanconi Anemia Group C Gaucher Disease Mucolipidosis Type IV Niemann-Pick Disease Type A/B Tay-Sachs Disease*** Dihydrolipoamide Dehydrogenase Deficiency Familial Hyperinsulinism Glycogen Storage Disease Type Ia Joubert Syndrome 2 Maple Syrup Urine Disease Type A/B Nemaline Myopathy Usher Syndrome Type IF Usher Syndrome Type III Walker-Warburg Syndrome RECOMMENDATIONS ACOG* ACMG* AJ* *ACOG - American Congress of Obstetricians and Gynecologists; ACMG - American College of Medical Genetics & Genomics; AJ - Ashkenazi Jewish Panel Recommended by national Jewish advocacy societies **Fragile X testing is recommended if indicated by a family history of fragile X syndrome, unexplained intellectual disability/autism, or premature ovarian failure. *** Tay-Sachs Disease testing is also recommended for individuals of Cajun or French Canadian descent. Carrier screening may also be appropriate for the partner of a known carrier or anyone with a family history of a genetic disorder Good Start Genetics, Inc. 237 Putnam Avenue Cambridge, MA Good Start Genetics Customer Care solutions@gsgenetics.com

20 2101 Woodwinds Dr., suite 100 Woodbury, MN W 65 th Street, suite 200 Edina, MN OPTIONAL CARRIER SCREENING FOR GENETIC DISEASES The goal of our practice is to make sure that you receive optimal care and attention to improve your chances of having a healthy pregnancy, and of course, a healthy child. An important part of family planning is being informed about your testing options. One of these options is genetic carrier screening. Carrier screening can help you understand your risk of having a child with genetic diseases. Typically, carriers are healthy individuals; but when two parents are carriers of the same genetic disease they can have a child affected with the disease. Most people do not know they are carriers until they have a child born with the disease. Our genetic test panel screens for diseases such as Cystic Fibrosis, Spinal Muscular Atrophy, Tay-Sachs disease, Sickle Cell disease, etc. Some genetic diseases can significantly impair a child s normal development. For some of these conditions, early treatment can improve pregnancy outcomes. Your doctor can provide you with the full list of tested diseases. If both you and your partner are carriers for the same disease, you child has a 1 in 4 (25%) chance of having that disease. If you are found to have a high reproductive risk, you have options. You may decide to have preimplantation genetic diagnosis, a prepregnancy process that significantly reduces the risk that a child will inherit the genetic disease, or undergo testing during your pregnancy to make informed reproductive decisions. Some individuals consider adoption or opt to not have children. Even if you would not choose any of these options, you can use the information to prepare for the birth of a child with a genetic disorder. You will have the opportunity to speak with your physician or a genetic counselor about the medical options available to you. Like any carrier screening test, some carriers will not be detected, so this test can reduce, but not eliminate the chance for a genetic disease. The genetic test panel is often covered by health insurance and you will be responsible for your deductible and/or co-pay. The test results will be available in about two weeks. Please sign below acknowledging that you and your partner will be screened. YES, I/We want screening. (Patient s Legal Name Please print) Patient signature Date NO, I/We do NOT want screening. (Patient s Legal Name Please print) Patient signature Date *THIS FORM MUST BE RETURNED AS SOON AS POSSIBLE* If you have questions about the screening, please call RMIA to discuss with a nurse 2017 G:Electronic Documents/1796 All Rights Reserved 8/3/17

21 RMIA CLINIC POLICIES Children in Clinic: We do not permit children into RMIA during regular hours. We struggled with implementing this regulation, and much deliberation and soul searching was required on our part. Factors which influenced our final decision included: A lack of trained RMIA personnel to safely caree for your children while you are undergoing procedures or consultations. Caring for your child can distract you from understanding the informationn and instructions given to you at your visit. It can be emotionally difficult for childless patients to sit in a waiting room in which small children are present. Patients in the waiting room may have newly diagnosed pregnancies in their earliest stages of development. During that time in gestation, developing fetuses are vulnerablee to viruses like rubella and chicken pox. These viruses are more prevalent in the pediatric age group. We wish to minimize the risk of such inadvertent exposures to our new mothers. Please realize that this has been a difficult decision. Our focuss is helping people have families. As such, children are very important to us. For the reasonss stated above, however, we cannot allow children to be brought here during clinic hours. Please schedulee your appointments at a time when child care is available to you. Confirmation of Appointments with Physicians: You will be contacted by RMIA 5 business days prior to a scheduled appointment. You must then advise us within the next business day of your inten to be seen. If you anticipate that you will be away during this confirmation period, please notify the scheduler ahead of time to avoid cancellation. Cancellation of Appointments with Physicians: If youu need to cancel your appointment, notify RMIA as soon possible. Failure to confirm your appointmentt will result in automatic cancellation. No penalty fee will be imposed, but you will need to reschedule your visit. If unable to keep your confirmed appointment, you must notify us no later than 3 business days before your scheduled visit (weekends do not count as business days) ). Failure to do so will incur a $250 charge to your account which must be paid before you can be rescheduled. Copy Charge: RMIA copies records at a fee of $1 per page (plus postage) for less than 5 pages and $15 cost-based fee plus 50 per page (plus postage) for more than 5 pages.. No Smoking Policy: RMIA maintains a smoke-free campus. Please refrain from smoking on RMIA premises (building, parking lot, etc. ) Cell Phones: Cell phones and other electronic communicatio on devices must be turned off at all times in the clinic. Food in the Clinic: Please no outside food. * Thank you in advance for understanding and complying with these policies * 2017 All Rights Reserved G:Electronic Documents/196 2/15/17

22 RMIA Woodbury 2101 Woodwinds Drive, Suite 100 Woodbury, MN Directions from Minneapolis and/or St. Paul I-94 East to I-494 South I-494 South to Lake Road (approximately 2-1/2 miles) Cross Lake Road onto Woodwinds Drive (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive Directions from the South I-35E North to I-494 East I-494 to Lake Road (approximately 10 miles) exit Lake Road, turn left (west) Lake Road (cross I-494) to Woodwinds Drive, turn right (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive Directions from the North I-35E South to I-694 East I-694 will change to I-494 south as it crosses I-94 I-694/I-494 to Lake Road (approximately 8 miles) exit Lake Road Cross Lake Road onto Woodwinds Drive (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive Directions from the East I-94 W to I-494 South I-494 South to Lake Road exit Lake Road Cross Lake Road onto Woodwinds Drive (north). RMIA is on the northeast corner of Lake Road and Woodwinds Drive G:Electronic Documents/208 10/7/16

23 RMIA Edina 3625 West 65 th Street Suite 200 Edina, MN Directions from St. Paul I-35W S to MN-62 W MN-62 W to France Ave. S. Turn left onto France Ave S. Turn left onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts) Directions from the West MN-62 E to France Ave. S. Turn right onto France Ave S. Turn left onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts) Directions from the North MN-100 S to MN-62 E MN-62 E to France Ave. S. Turn right onto France Ave S. Turn left onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts) Directions from the South I-35W N to I-494 W I-494 W to France Ave. S. Turn right onto France Ave S. Turn right onto W 65th St. Go 1 block to the 4-way stop (Drew Ave.) Go straight through the 4-way stop and take an immediate right into our parking lot, underneath the Southdale Medical Arts building (the building is on stilts) G:Electronic Documents/208 10/7/16