FINANCIAL AGREEMENT
MoonDragon Birthing Services & Woman Care
MDBS Maternity Care & Domiciliary Midwifery
Rev. Leather Dupris, BS Candidate, DEM, CCE
Owner & Director of Services
0 Boardman Street, #1
Salem, MA 01970
Office: (978) 744-5583
Fax: (978) 741-2015
Website: www.moondragon.org
MoonDragon Birthing Services 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 phone time, 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.
MoonDragon Birthing Services does 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 MoonDragon Birthing Services 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
- Reiki Therapy
- Notary Public Services - Commonwealth of Massachusetts
- Pastoral Spiritual Counseling
MoonDragon Birthing Services 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 Pampering Services (Home Health) care for new moms
- Reiki Therapy Services beyond 6 weeks postpartum.
- Membership in MMA & MANA
MoonDragon Birthing Services 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 MDBS services) 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 Salem Center. Gas money will be provided
at the time of the visit at the rate of $0.35 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, MoonDragon 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 MoonDragon Birthing Services
and attendants during the prenatal period, labor, birth, and postpartum are the legal
property of MoonDragon Birthing Services 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 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 MoonDragon Birthing Services 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 MoonDragon Birthing Services 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)
______________________________________
Date
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: $2800.00 - 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 $25.00 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 15% discount if the full amount is
paid on or prior to the 37th week of pregnancy. This is a savings of $420.00
($2800.00 - $420.00 for a total discounted fee of $2380.00). 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 MDBS. The client will still be responsible for any amount
not covered by their medical insurance.
Individual Fees Option:
PRENATAL:
Initial Consultation $125.00 - This includes medical history, exam, consultation.
Prenatal Visit $75.00 - Standard prenatal care, home-visit + travel.
Prenatal Visit $75.00 - Standard prenatal care, office visit.
A minimum prenatal visit charge will be for 6 visits ($450.00) 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 $20.00 - Up to 10 minutes.
Phone Consultation $35.00 - Up to 30 minutes.
Phone Consultation $60.00 - 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
Labor & Birth Visit(s) $1800.00 - 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 50% of the birthing fee only if MDBS 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 CARE
Postpartum Visit $75.00 - Maternal assessment & care, consultation, home visit.
Postpartum Visit $55.00 - Newborn assessment & care when included with maternal visit,
home + travel.
Postpartum Visit $75.00 - Newborn assessment alone, home visit + 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 ($225.00 maternal + $165.00 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
3-5 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 $75.00 will be charged to you and payable to MDBS to activate your billing
account with our billing service. This fee is paid 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 $25.00. These prices are subject to change by the billing
service without notice to MDBS or to the client.
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:
Home Health Care
$20.00 / hour - Personal care for mother and/or infant. Grocery shopping,
light house keeping, meal preparation and any other services that the mother may require
during her postpartum period.
Reiki Therapy
$25.00 - Healing energy working using Reiki therapy techniques as a specific treatment for
a condition. This is a partial treatment for a specific purpose or body area. Usual time
involved is about 30 to 45 minutes.
$45.00 - Full body treatment. Lasts about 45 minutes to 90 minutes or more. Reiki therapy
is included in prenatal, birth and postpartum care for established MDBS clients at no extra
charge.
Notary Public
$5.00 - Massachusetts Commission. Free to MDBS clients.
Pastoral Counseling
By Donation - Spiritual counseling and pastoral duties which may include individual or
family counseling with an ordained minister and high priestess of Wicca. Counseling for
MDBS clients is included in MDBS services.
MoonDragon Birthing Services & Home Health Care Client Sliding Fee Scale for Services
| Yearly Income |
Monthly Income |
Weekly Income |
Adj. MDBS Fee
(With Publicity) |
Adj. MDBS 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 MoonDragon Birthing Services. 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. MDBS 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.
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