Healthcare Midwifery Group Form

Healthcare Midwifery Group Form

Client Name:   Date of Birth:   Medical Record / ID (if known):

Patient Information

Insurance Information

Medical and Obstetric History

Obstetric History — G (gravida):   P (para):   Term births:   Preterm births:   Abortions:   Living children:

Prenatal Care Details

Expected Due Date:   Gestational Age at First Visit:

Informed Consent for Midwifery Care

I authorize the licensed midwifery team and authorized assistants to provide prenatal, labor, birth and postpartum care consistent with the scope of midwifery practice. Midwifery care includes history and physical examination, routine laboratory testing, fetal assessment, vaginal examinations when indicated, suturing of perineal tears, and administration of medications commonly used in midwifery practice. I understand that midwives may consult with or refer to other health care providers or transfer care when clinically indicated.

Potential benefits include individualized prenatal attention, support during labor, and avoidance of unnecessary interventions. Potential risks include unforeseen maternal or fetal complications, need for hospital transfer, surgical delivery, hemorrhage, infection, or other adverse outcomes. I understand that no guarantee can be made as to the results of care or that labor will progress without intervention.

Alternatives include hospital-based obstetric care, consultation with an obstetrician, or transfer of care at any point. I have had the opportunity to ask questions and have received answers to my satisfaction. I understand I may revoke this consent at any time, but revocation will not apply to actions already taken based on this consent.

I consent to midwifery care as described above.

I consent to routine prenatal testing and immunizations as recommended by my care team.

Release of Records & Assignment of Benefits

I authorize the release of medical information related to my care to other health care providers, hospitals, insurance carriers, and designated third parties when necessary for continuity of care or for billing and payment of claims. This authorization includes records concerning prenatal care, labor and delivery, postpartum care, and newborn records relevant to the patient's treatment.

This authorization expires on:

I assign benefits payable for services rendered to me to the midwifery practice and authorize my insurer to make payment directly to the practice where permitted. I understand I remain financially responsible for charges not covered or paid by my insurer.

Privacy and HIPAA Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my protected health information may be used and disclosed. I authorize release of necessary health information for treatment, payment, and health care operations in accordance with applicable law.

I acknowledge that I have been offered or provided the Notice of Privacy Practices.

Emergency Treatment & Transfer

In the event of an emergency or if the midwifery team determines hospital transfer is necessary for the safety of the patient or fetus, I consent to emergency treatment and transport to an appropriate facility. I understand transfer may be urgent and that the midwives will attempt to notify my emergency contact as soon as possible.

I consent to emergency treatment and transfer as described above.

Optional Authorizations

I consent to the presence of student midwives or approved observers during my care for educational purposes.

I consent to routine clinical photography for medical records. I understand any photographs used for teaching or publication will be de-identified unless separate written consent is obtained.

Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that providing false information may affect my clinical care and financial responsibility. By signing below I confirm that I have read and understand the consents and authorizations contained herein.

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