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MoonDragon's Pregnancy Information

A Webpage Template of Client File Forms


[Name of Midwifery Service]
Maternity Care & Domiciliary Midwifery

[Name of Midwife]
[Address of Midwife]
Office: [phone number]
Fax: [phone number]
Cellphone: [phone number]
Website: [Your Midwifery Website URL]

[Midwifery Service Name] is financed solely on the contributions of its clients. The hiring of qualified birth consultants (midwife and attendants) is our primary expense. Books and educational services for our consultants and our clients combined with client support efforts are other important financial expenditures. Traveling expenses to and from client visitations, births and postpartum care combined with automobile upkeep and insurance coverage are expenses involved with transportation. Advertising expenses include paper and printing, publishing and distributing information for community awareness; copy costs for files, education, newsletters, and our website and internet costs. Expenses which occur by obtaining samples and equipment for births (beyond what the clients are supposed to obtain), maintenance and servicing of equipment, laboratory supplies, well-woman care and supplies; phone expenses for separate lines and cell phonetime, electronic computers, printer, fax machine expenses, rent, electricity, and heating expenses and so forth are only some of our major expenses that we must meet each and every month. We do not receive any public or private funds to help defray these costs.

Our maternity care services are available to all healthy, low-risk pregnant women and their babies, regardless of their ability to pay for our rendered services. Some families may have health insurance coverage which will pay for our services, however, many of our common HMO's and other similar policies do not cover out-of-hospital" (OOH) maternity and birthing care. Due to this serious health care restriction, we have developed means for these families, and families without health insurance, to be able to afford quality homebirth midwifery care and service. This means that some clients may be able to pay more than other financially stressed clients may be able to afford. Financial arrangements can be made to fit the individual client's budget by several methods. We have developed a flexible sliding fee scale for low income families which is dependent upon household income, financial hardship and the client's willingness to help promote our services to other expectant mothers and their partners.

Other options available are:
(1) To help defray the costs, exchange of services (bartering) is a possibility upon agreement by both parties.
(2) Some costs may be adjusted with promotional endeavors and assisting our expanding service by bringing new qualifying clients to us.
(3) We are always open to gifts and donations from other sources.
(4) We are open-minded to suggestions by our clients. We can be inventive together.

Whatever method is chosen, this agreement must be made and in place prior to the 37th week of pregnancy or the birth and must be agreed upon by both parties.

The [Midwifery Service Name] Financial Agreement for Our Services Is:

This Includes:
  • Birth Consultant (Midwife) & Attendants of the Consultant's Choice
  • Pregnancy Testing
  • Pregnancy Counseling
  • Nutritional Counseling
  • Prenatal Screening
  • Prenatal Visits (as outlined in the Practice Guidelines)
  • Private Educational Tutoring & Childbirth Preparation
  • Home Birth & Neonatal services, Breastfeeding Instruction & Support
  • Birth Supplies & Equipment supplied by Birth Consultant (Midwife)
  • Suturing of Perineal Tissue, if needed up to a 3rd degree tear
  • Postpartum Care for approximately 6 to 8 weeks after birth
  • Electronic, Phone, or Post Office Communications

Other Services Available:
  • Breast Exam Education
  • Parenting Education & Support
  • [List other services you provide]

[Midwifery Service Name] will provide these services at a financial cost to the client:
  • Clinical laboratory testing by an outside reference laboratory
  • Pap smears, either by standard slide method or by Thin Prep method
  • Insurance submissions through our billing services
  • Contraceptive counseling and barrier method fittings
  • Postpartum Care Services (Home Health) care for new moms
  • [Specialized Therapy & Well Woman Care] Services beyond 6 weeks postpartum.
  • Membership in [State and/or National Midwifery & Professional Organizations]

[Midwifery Service Name] DO NOT provide these services:
  • Circumcision or other forms of newborn genital mutilations
  • Hospital or birth center births, other than birth support
  • Prescribe or give drugs before, during or after the birth.
  • Suturing of perineal tissue with a third or fourth degree tear
  • Cesarean births, other than birth support.

The Birthing Parents will supply and be responsible for obtaining and paying for the following:

Educational Items: (books, videos, etc. not supplied by the [Midwifery Service Name] and outside childbirth preparation classes.

Medical Laboratory or Diagnostic Tests: (Requested tests may include prenatal blood work, urinalysis, dietary analysis, nutritional supplements, viral blood screening (HCV, HBV, HIV, VDRL, Herpes, Strep B, Chlamydia, etc.), ABO-Rh blood typing and antibody screening, and any other medical tests that may be necessary in providing good prenatal care to the mother and baby and aid in the detection and management of possible birth complications. This may include amniocentesis for chromosomal analysis, or an ultrasound for fetal or placental concerns.

Birthing Supplies & Nutritional Supplements (see separate list).

Rh Antibody Testing and Rhogam Treatment: In the case of an Rh negative mother and an Rh positive infant. This may include lab tests done on cord samples to determine the baby's blood type.

Cord Blood Preservation of Stem Cells.

Any hospital, clinical, physician, nursing, doula expenses related to the present pregnancy and any postpartum care.

Prescriptions & Non-Prescription Medications required by the mother and/or infant related to the present pregnancy and postpartum care.

Emergency Care Expenses which may include taxi or ambulance transport, emergency room and physician expenses, surgery and medications.

Mileage for Home Visits, unless agreed upon otherwise, the birthing parents will be responsible for traveling costs of the birth consultant (the midwife) and her attendants for any mileage beyond 10 miles, round trip, of (your city or town where you have your midwifery practice). Gas money will be provided at the time of the visit at the rate of $ _____________________ per mile.

If other foreseen expenses are to occur, the birth consultant (midwife) has the obligation and responsibility to discuss them with the parents ahead of time and come to agreement with the parents.

Since money is tight, [Midwifery Service Name] recommends contribution payments should be arranged so that the full amount is paid by t he time of the expected due date. It is important to try to meet this payment-due-in-full date since our parents have found that many expenses occur after the birth of their baby.

If a financial hardship occurs or if the pregnancy terminates in a medical setting prior to the 37th week of pregnancy, the remaining amount due on the financial contract needs to be re-negotiated by both parties. After the 37th week, if labor has begun and our birth consultant (midwife) are in attendance whether or not an emergency transfer is necessary and occurs during labor, birth, or postpartum, all remaining payments or fees/contributions are due, regardless of the final location of mother and/or infant. Our services are available for clients up to 6 weeks postpartum, regardless of birth location, unless otherwise negotiated. An example of this would be an emergency transfer for a placenta previa (placenta covering the opening of the cervix which hinders the birthing capability of the fetus), possibly complicated by hemorrhaging, with or without labor. This situation would be an indication for emergency transfer for the mother and baby's safety with a resulting cesarean delivery as the most likely outcome. However, our attendants will accompany the mother to the emergency facility. Copies of client medical records will need to be transferred to the receiving medical staff, but, only after the client has given written authorization to release the medical records. Our attendants can assist the mother with emotional support and liaison assistance before, during, and after the birth of the mother and her baby. Our care would continue after their postpartum return home with assistance in breastfeeding support, maternal and infant care, parenting skills education and possible contraceptive discussing and choices.

All fees and contributions are non-refundable. We feel the services we have to offer are well worth the compensation we ask and agree to with the clients. The time, energy and devotion of our birth attendants go fare beyond what they receive in payment. We could not do the work we do without the financial help and support of our clients.

Any photos, stories, and other client materials obtained by [Midwifery Service Name] and attendants during the prenatal period, labor, birth, and postpartum are the legal property of [Midwifery Service Name] and may be used in the promotion of our services, whether it is electronically or otherwise used. The exception of this clause would be the private client medical records, which would be kept confidential and protected, unless otherwise granted by written permission by our client or subpoenaed by a legal court of law. Our clients are entitled to one free copy of all medical records; photos and other materials that may be obtained by (Midwifery Service Name) while under our service contract.

Our Birth Consultant (midwife) reserves the right to decline further care in the event of non-payment on agreed terms, client medical or psychological reasons, or because of noncompliance / uncooperation on the part of one parent or both. The client reserves the right to discontinue our services at any time with written notice if they are not completely satisfied with our services.

I / We _______________________________________________________________________
have read all sections of this disclosure and have discussed each section with each other and with the Birth Consultant (Midwife) and [Midwifery Service Name] regarding the financial obligation of the services rendered. We do hereby understand and acknowledge all information, terms and ramifications. We execute it voluntarily and with full knowledge of its significance.

We agree to pay the amount of: $_________________________________________ in payments of $___________________ Per Month / Visit. In addition or in lieu of payment, we agree to compensation by other means, such as an exchange of services or talents by


Birth Consultant (Midwife)

Parent #1 (Mother)

Parent #2 (Partner)

Legal Guardian (if applicable)


Addendum to this Agreement:







Standard Fee Schedule & Payment Choices

These are our standard fees for our services. These are the fees that will be charged to our birthing clients that do not qualify for financial hardship or will be billed to your insurance company.

Global Fee Option:

Standard Global Fee: $____________________________________ - Prenatal, Birth & Postpartum care in one condensed fee.

This includes all care from pregnancy testing, initial consultation, unlimited prenatal visits with standard medical testing using out of laboratory methods, nutritional consultation and counseling, prenatal education & preparation, homebirth services, postpartum care up to 6 weeks with unlimited visits as needed. All phone consultations & Reiki therapy treatments are included. This must be paid in full by 6 weeks postpartum. After 6 weeks postpartum, a late fee of $___________________ will be added each month the account is in arrears, unless other payment options are agreed upon. This often saves you several hundred dollars if you need frequent visits, counseling and services. It also eliminates billing-payment confusion.

We offer our standard global fee birthing clients a _______________% discount if the full amount is paid on or prior to the 37th week of pregnancy. This is a savings of $____________________ for a total discounted fee of $_________________________. Both the standard global fee and the discounted global fee are for non-insurance clients only and are non-refundable regardless of pregnancy-birth outcomes and place of birth. If paying by health insurance, this option cannot be submitted until after the birth and may take several weeks to months for payment to be received by [Midwifery Service Name]. The client will still be responsible for any amount not covered by their medical insurance.

Individual Fees Option:

Initial Consultation $_________ - This includes medical history, exam, consultation.
Prenatal Visit $________ - Standard prenatal care, home-visit + travel.
Prenatal Visit $________ - Standard prenatal care, office visit.

A minimum prenatal visit charge will be for 6 visits ($_______________) if client signs on with our services after the 35th week of pregnancy. Clients prior to 35 weeks of pregnancy will follow our prenatal care guidelines for frequency of visitations. The prenatal fees are to be paid at the time of services, including traveling fees as indicated in the Financial Agreement. Fees include standard prenatal care & assessment, nutritional counseling and prenatal education & birth preparation.

Phone Consultation $______________ - Up to 10 minutes.
Phone Consultation $______________ - Up to 30 minutes.
Phone Consultation $______________ - Up to 1 hour. Any longer, an office or home visit will be scheduled.

This does not include scheduling or changing appointments. This fee is for prenatal concerns and discussion of personal, family, or health issues.


Labor & Birth Visit(s) $_________________- This includes unlimited labor visits, labor support, as needed or desired by the laboring woman, birthing care and support, immediate postpartum care & assessment for mother and newborn, and lactation consultation and support.

The birthing fee will be paid no later than 3 weeks prior to the due date. If you are referred to other medical care or you choose to opt for another caregiver prior to labor after 37 weeks, you may receive a refund of __________% of the birthing fee only if [Midwifery Service Name] is no longer providing care or support during the remainder of your pregnancy, labor, birth or postpartum and it is agreed upon by both parties.

If you go into labor and the midwife and any birthing attendants (of the midwife's choice) arrive to attend your labor, regardless of outcome and final place of birth, the birthing fee will not be refunded. The midwife will continue to provide labor support and lactation consultation, if the client desires, even if the birth process is transferred to a medical facility during labor, the birth and immediately postpartum. This service is included in the birthing fee.


Postpartum Visit $_________ - Maternal assessment & care, consultation, home visit.
Postpartum Visit $_________ - Newborn assessment & care when included with maternal visit, home plus travel.
Postpartum Visit $_________ - Newborn assessment alone, home visit plus travel.

The postpartum fees are to be paid at the time of services, including traveling fees, if applicable, for home visits as indicated in the Financial Agreement. A minimum of three visits will be charged ($__________ maternal plus $__________ for newborn) if client discontinues or refuses postpartum care prior to two weeks postpartum. If the mother chooses to have a PKU performed (these are not always successful if enough blood is not obtained for the test and are often traumatic for the infant), this is included in the Newborn assessment 3 to 5 days postpartum.

All fees are to be paid no later than the 6th week postpartum at the final postpartum visit. There are no refunds of any paid fees unless agreed upon by both parties. Our fees are market fair and comparable to other practitioners providing similar services.

Other fees: If you do have health insurance that covers homebirths and midwives, an initial fee of $________________ will be charged to you and payable to [Midwifery Service Name] to activate your billing account with our billing service. This third party fee is paid directly to the billing service to open up your account and submissions made to your insurance company for payment. If you have health insurance and do not know if it covers homebirths and midwives, the billing service will investigate it for an additional $____________. These prices are subject to change by the billing service without notice to [Midwifery Service Name] or to the client and are not refundable.

We currently accept Visa, MasterCard, Discover & American Express credit cards for birthing service payments. This way you can spread out the fees using your credit card. No surcharge will be added.

Other Services Offered:

(Add any other services you provide along with description and fees).

[Midwifery Service Name] Client Sliding Fee Scale for Services [Use as a guideline to develop your own sliding scale]

Yearly Income Monthly Income Weekly Income Adj. Midwifery Fee
(With Publicity)
Adj. Midwifery Fee
(W/O Publicity)
Under 8,000 Under 667 Under 167 250 500
8,000 - 9,000 667 - 750 167 - 188 300 600
9,000 - 10,000 750 - 833 188 - 203 350 700
10,000 - 11,000 833 - 916 203 - 229 400 800
11,000 - 12,000 916 - 1,000 229 - 250 450 900
12,000 - 13,000 1,000 - 1,083 250 - 270 500 1,000
13,000 - 14,000 1,083 - 1,166 270 - 291 550 1,100
14,000 - 15,000 1,166 - 1,250 291 - 312 600 1,200
15,000 - 16,000 1,250 - 1,333 312 - 333 650 1,300
17,000 - 18,000 1,333 - 1,417 333 - 354 700 1,400
18,000 - 19,000 1,417 - 1,500 354 - 375 750 1,500
19,000 - 20,000 1,500 - 1,583 375 - 395 800 1,600
20,000 - 21,000 1,583 - 1,666 395 - 416 850 1,700
21,000 - 22,000 1,666 - 1,750 416 - 437 900 1,800
22,000 - 23,000 1,750 - 1,833 437 - 458 950 1,900
23,000 - 24,000 1,833 - 1,917 458 - 479 1,000 2,000
24,000 - 25,000 1,917 - 2,000 479 - 500 1,050 2,100
25,000 - 26,000 2,000 - 2,083 500 - 521 1,200 2,400
26,000 - 27,000 2,083 - 2,166 521 - 542 1,450 2,500
27,000 - 28,000 2,166 - 2,333 542 - 583 1,600 Standard Fees
28,000 - 29,000 2,333 - 2,417 583 - 604 1,750 Standard Fees
29,000 - 30,000 2,417 - 2,500 604 - 625 1,900 Standard Fees
30,000 - 31,000 2,500 - 2,583 625 - 646 2,050 Standard Fees
31,000 - 32,000 2,583 - 2,666 646 - 666 2,200 Standard Fees
Greater than 32,000 Greater than 2,666 Greater than 666 Standard - 10 % Standard Fees

This income is considered gross income (before taxes and other deductions).

"With publicity" discounts, means that the expectant mother (and her partner) will actively assist us in promoting our services by the use of photography and electronic (website) promotions, talking to other expectant mothers about our services, and any other means of helping us advertise, promote, and inform other expectant parents about services available through (Midwifery Service Name). This discounted rate not only helps the mother and her family financially, but it also helps Us to "get the word out" among the community since our only advertising or promotion is done through our website and not all women considering homebirth have access to online information.

This sliding scale is for reference only. These fee rates are not set in stone. Changes may be made without notice as expenses increase. [Midwifery Service Name] will work with each individual family's financial situation and if hardship is proven, we will adjust our fees accordingly. Every woman deserves a positive birth experience and every baby deserves a good beginning. All we ask is that the amount that is agreed upon is paid promptly and fully.

MoonDragon's Client Forms Index
MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
MoonDragon's Pregnancy Index
MoonDragon's Womens Pregnancy Health Information Index
MoonDragon's Pediatric Information Index
MoonDragon's Parenting Information Index
MoonDragon's Nutrition Information Index

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