Healthcare Birth Contract

HEALTHCARE BIRTH CONTRACT

This Healthcare Birth Contract (the Contract) is entered into by and between Patient Name: and Provider Name: . Contract Effective Date:

Patient Information

Insurance Information

Medical History & Current Health

Planned Care and Delivery

Scope of prenatal, delivery, and immediate postpartum services to be provided by Provider includes routine prenatal visits, labor management, delivery care, neonatal resuscitation within standard hospital/clinic protocols, and postpartum follow-up for up to weeks following delivery.

Risks, Benefits, and Consent

Provider has explained to Patient the nature of anticipated prenatal and delivery care including common and material risks (including but not limited to hemorrhage, infection, emergency cesarean delivery, anesthetic complications, neonatal complications, and maternal morbidity). Patient acknowledges receipt of such explanation and understands that not all risks can be listed here, and that complications may require immediate interventions.

Patient consents to routine interventions and agrees that in the event of an unforeseen complication Provider may perform additional procedures deemed necessary for the health and safety of Patient and/or newborn. Where possible, Provider will attempt to obtain additional informed consent prior to non-emergent procedures.

Newborn Care, Testing, and Specimens

Provider will attend to immediate newborn care, including assessment, standard newborn screenings, and stabilization. Parent authorizes routine newborn care and screenings unless otherwise indicated below.

Fees, Billing, and Financial Responsibility

Patient is responsible for applicable fees for prenatal care, delivery, anesthesia, facility charges, newborn charges, and any additional services not covered by insurance. Provider will bill insurance when authorized; Patient remains ultimately responsible for balances not paid by insurance.

Termination, Modification, and Transfer of Care

This Contract may be modified by written agreement of Patient and Provider. Provider retains the right to transfer care or terminate this Contract for safety concerns, non-compliance, or non-payment, in which case Provider will make reasonable efforts to refer Patient to alternative appropriate care.

HIPAA and Authorization

Patient acknowledges receipt of Provider's privacy practices and authorizes Provider to use and disclose protected health information for treatment, payment, and health care operations consistent with applicable law. Patient further authorizes release of medical information to insurance carriers, emergency contacts, and other providers involved in care.

Representation, Indemnity, and Governing Law

Each party warrants that it has the authority to enter into this Contract. Patient agrees to indemnify and hold Provider harmless from liability arising from Patient's failure to disclose relevant medical information or failure to follow reasonable medical advice. This Contract will be governed by the laws of the state in which Provider performs the delivery services.

Acknowledgment and Certification

By signing below Patient certifies that all information supplied in this Contract is true and complete to the best of Patient's knowledge, that Patient has had the opportunity to ask questions and receive answers, and that Patient understands the rights and responsibilities set forth herein.

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