*** Transcriber's Note: Please set your voice synthesiser to read most punctuation. When you encounter the caret sign (^) at the end of a line, please enter the applicable information, if necessary. ***

Department of Internal Affairs – Te Tari Taiwhenua

BDM406

Access to and disclosure of indentifying information 

Last updated: 23 April 2024

Part 1: Before you apply 

Use this form if you are a donor or donor-conceived person and you want to provide or cancel your consent to the release of your identifying information from the Human Assisted Reproductive Technology (HART) Register. Identifying information is any information that can be used to identify you, such as your full name or date of birth. 

How to submit your application
You can fill out and submit this application form if you are: 
• a donor who donated before 22 August 2005 
• a donor-conceived person who is aged 18 or older
• a donor-conceived person aged 16 or 17 who has the approval of the Family Court and has attached a copy of the order from the Family Court
• a guardian of a donor-conceived person, if the donor-conceived person is under 18 years of age and does not have the approval of the Family Court to complete the form
• an agent authorised by a donor, donor-conceived person aged 18 or older, or a guardian of a donor-conceived person aged 17 or under (attach a BDM405 Authorisation for disclosure of information to agent form).
You can either give this completed form to your fertility service provider or post to:
HART Team
Births, Deaths & Marriages
PO Box 1052
Wellington 6140. 
You can also scan pages 2 to 4 and email to: BDM.Hart@dia.govt.nz

Who can access your identifying information
If you are a donor who donated before 22 August 2005, all identifying information held by the fertility clinic or Births, Deaths and Marriages (BDM) can be given to:
• people conceived by your donation aged 18 or over, or
• guardians of people conceived by your donation aged 17 and under.
The fertility clinic or BDM will tell you if someone accesses your identifying information.
If you are a donor-conceived person:
• your donor can request to know your sex, regardless of whether you or your guardian has given consent
• you (or your guardian if you are aged under 18) must give consent using this form before your donor or people related to the same donor can access your identifying information.
The fertility clinic or BDM can refuse a request to access your information if disclosure is likely to endanger any person.

Contact details
Website: govt.nz/bdm/contactus
Email: bdm.nz@dia.govt.nz

Part 2: Form begins

How to answer:
• You can complete this form by hand or on-screen using Adobe Acrobat Reader.
• You can use the Tab key to move to the next fillable form field in Adobe Acrobat Reader.
• You must still print off the application and sign where applicable by hand.

1.  I am submitting this application to:
Births, Deaths and Marriages, yes or no ^
My fertility clinic (fill out name and address below), yes or no ^

Name and address of fertility clinic ^

2.  I am a:
A donor who donated before 22 August 2005, yes or no ^
A donor-conceived person who is aged 18 or older, yes or no ^
A donor-conceived person aged 16 or 17, authorised by the Family Court (attach Family Court order), yes or no ^
A guardian of a donor-conceived person aged under 18 years, yes or no ^
An agent (for example, a lawyer) acting on behalf of a donor-conceived person or their guardian, (attach completed BDM405 Authorisation for information to agent form), yes or no ^

3.  My fertility service provider identifier (if known)
Identifying number or symbol ^

4.  I give my consent to release my identifying information (tick one, if applicable)
Fill in this section if you wish to consent to the release of your identifying information. If you wish to cancel the consent you have previously given, fill in section 5. 
I am a donor who donated before 22 August 2005 and I consent to people conceived by my donation receiving my identifying information, yes or no ^
I am a donor-conceived person and I consent to donor-conceived people that share my donor receiving my identifying information, yes or no ^
I am a donor-conceived person and I consent to my donor receiving my identifying information, yes or no ^

5.  I cancel the consent I have given (tick one, if applicable)
Fill in this section if you wish to cancel the consent you have previously given. If you wish to consent to the release of your identifying information fill in section 4. 
I am a donor who donated before 22 August 2005 and I cancel the consent for people conceived by my donation to receive my identifying information, yes or no ^
I am a donor-conceived person and I cancel the consent for donor-conceived people that share my donor to receive my identifying information, yes or no ^
I am a donor-conceived person and I cancel the consent for my donor to receive my identifying information, yes or no ^

6.  My details
6a. Current name
Current first name(s) ^
Current surname ^
6b. Name at birth (if different from above)
First name(s) at birth ^
Surname at birth ^
6c. Place and date of birth
Village, town or city of birth ^
Country of birth ^
Date of birth (dd/mm/yyyy) ^

7.  Referee declaration 
This section must be completed by another person who is 16 years or older.
I declare that:
• I am 16 years of age or over.
• I have known the applicant for at least 6 months, or have seen their government issued photo identification.
• I am satisfied the named person’s identity information stated on page 3 of this BDM406 Access to and disclosure of identifying information form is true and correct.

Signature of referee ^
Date signed (dd/mm/yyyy) ^
Full name of referee ^
Contact phone number ^
Contact address of referee ^