Healthcare Postpartum Agreement

HEALTHCARE POSTPARTUM AGREEMENT

Patient Information

Insurance & Billing

Medical & Postpartum History

Scope of Postpartum Services

Effective Date:

Provider Name:

The Provider agrees to deliver postpartum services as selected below. Services are supplemental to medical care provided by the patient’s obstetrician, midwife, or pediatrician and do not replace emergency or urgent medical treatment.

Consent, Risks, Limitations & Patient Responsibilities

By signing this Agreement, Patient consents to the selected postpartum services. Patient acknowledges that Provider will act within the scope of training and applicable standards, but that clinical outcomes cannot be guaranteed. If clinical signs or symptoms indicate medical concern, Provider will recommend or initiate referral to emergency or primary medical providers.

Patient Responsibilities include: notifying Provider of medical history changes, following clinician-directed referrals and physician orders, providing accurate information regarding medications and allergies, and ensuring a safe environment for home visits. Patient accepts financial responsibility for services not reimbursed by insurance.

Known risks associated with postpartum visits and lactation support are minimal but may include transient discomfort during breast assessment, wound sensitivity, or emotional distress when discussing mental health. Provider will use clinical judgment to minimize risks and will document findings and recommendations in the care record.

Confidentiality / HIPAA Acknowledgment

All personal health information collected by Provider is subject to privacy protections. Patient acknowledges receipt of the Provider’s privacy practices summary and authorizes Provider to create and maintain a medical record documenting services. Patient authorizes disclosure of relevant health information to other treating providers, insurance carriers for payment, and to emergency contacts as necessary for care coordination.

Fees, Payment & Cancellation

Patient agrees to pay Provider fees as quoted at the time of scheduling. Insurance billing will be attempted with provided information, but Patient remains ultimately responsible for charges not covered. Cancellation policy: Patient will notify Provider at least 24 hours in advance of a scheduled visit or may be charged a late cancellation or no-show fee.

Termination, Liability & Indemnification

Either party may terminate this Agreement upon written notice. Provider reserves the right to discontinue services if Patient fails to follow recommendations, presents unsafe conditions, or demonstrates behavior that places staff at risk.

Provider liability is limited to direct damages arising from gross negligence or willful misconduct. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient’s failure to follow medical advice, inaccurate disclosures of medical history, or unauthorized refusal of recommended medical follow-up.

Acknowledgements & Certifications

Patient certifies that all information provided on this form is true and complete to the best of their knowledge. Patient acknowledges being informed of the nature and scope of the postpartum services, understands the risks and limitations described herein, and consents to receive care from the Provider.

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