Healthcare Newborn Contract

HEALTHCARE NEWBORN CONTRACT

Facility Name:    Attending Physician:

I. PARTIES AND RECITALS

This Newborn Contract is entered into between the Facility named above (the "Provider") and the individual signing below (the "Signer"), who is the parent or legal guardian acting on behalf of the newborn patient identified herein. The Signer acknowledges authority to authorize medical care and financial responsibility for the newborn.

II. NEWBORN PATIENT INFORMATION

Date of Birth:    Time of Birth:    Sex:

III. PARENT / GUARDIAN INFORMATION

Phone:    Email:    Emergency Contact:

IV. INSURANCE AND BILLING

Policy Number:    Group Number:    Subscriber Name:

By signing this Agreement the Signer authorizes the Provider to bill the listed insurance and assigns insurance benefits to the Provider to the extent permitted. The Signer remains financially responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services.

V. MEDICAL HISTORY & ALLERGIES

VI. ROUTINE NEWBORN CARE CONSENT

The Signer authorizes the Provider and its clinicians to provide routine newborn care and treatment as medically indicated, which may include neonatal assessment, feeding support, basic laboratory screening, metabolic/newborn screening heel stick, hearing screen, prophylactic medications, immunizations indicated at birth, and other routine procedures.

Consent for the following routine interventions (check to authorize):

Vitamin K injection for prevention of hemorrhagic disease of the newborn
Erythromycin ophthalmic prophylaxis
Hepatitis B vaccine at birth
Newborn metabolic and hearing screening tests
Routine blood draws and clinical monitoring as medically indicated

Optional procedure consent (if applicable). Circumcision: I authorize circumcision and understand an additional consent form and fee may apply.

VII. RISKS, BENEFITS, AND RIGHT TO WITHDRAW

The Signer acknowledges receipt of an explanation of the benefits and reasonably foreseeable risks associated with routine newborn care and the optional procedures listed above. The Signer understands that refusal of recommended care may increase the risk of harm to the newborn. The Signer may withdraw consent at any time in writing, except where emergency care is required to prevent serious harm or death.

VIII. EMERGENCY TREATMENT AUTHORIZATION

In the event of an emergency requiring immediate treatment to prevent serious harm, the Signer authorizes the Provider to provide any necessary emergency medical or surgical treatment and to transfer the newborn to an appropriate facility if required. The Signer acknowledges that such emergency care will be rendered in the best clinical judgement of the treating clinicians.

IX. AUTHORIZATION FOR RELEASE OF INFORMATION & HIPAA ACKNOWLEDGMENT

The Signer authorizes the Provider to release medical information as necessary for treatment, payment, or health care operations and acknowledges receipt of the Provider's Notice of Privacy Practices. The Signer understands that authorizations for other disclosures must be made in writing and may be revoked in writing except to the extent that action has been taken in reliance on the authorization.

HIPAA Acknowledgment: I acknowledge that I have been provided with information on privacy practices and that I understand my rights regarding protected health information.    Initials:

X. FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS

The Signer agrees to be financially responsible for all charges for services provided to the newborn that are not paid by insurance. The Signer assigns to the Provider all rights and benefits to payment from any third-party payor to the extent of services rendered. The Signer authorizes release of information to effect payment and agrees to cooperate with claims processing.

XI. REPRESENTATIONS, WARRANTIES AND INDEMNITY

The Signer represents that the information provided on this Contract is true and complete to the best of their knowledge. The Signer agrees to indemnify and hold the Provider harmless from any claim, loss, or expense arising from misrepresentation of insurance coverage or authority to consent on behalf of the newborn.

XII. LIMITATION OF LIABILITY; DISPUTE RESOLUTION

Except in cases of gross negligence or willful misconduct, the Provider's liability for any claim arising from the care provided under this Agreement is limited to reasonable charges for services rendered. Any dispute arising under this Agreement shall be submitted to good faith negotiation; if unresolved, the parties may pursue mediation or other mutually agreed alternative dispute resolution methods prior to initiating litigation.

XIII. TERM, MODIFICATION, AND EXPIRATION

This Contract is effective as of the date signed below and shall remain in effect until the earlier of: (a) revocation in writing by the Signer, (b) formal discharge of the newborn from Provider care, or (c) the Authorization Expiration Date specified below.

XIV. CERTIFICATION

By signing below, the Signer certifies that they have the legal authority to consent to medical treatment for the newborn. The Signer acknowledges that they have read and understand the terms of this Contract, that questions have been answered, and that signing constitutes informed consent for the authorized procedures and financial terms described herein.

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