Insurance Billing Contract

The following sets forth an agreement between PVD Doula and Barefoot Mama Doula Services:

As Professional Birth Doulas, our role is to provide support to clients in labor and their partners. This includes non-medical comfort measures and emotional support throughout labor and birth. We will draw on our professional training, knowledge and experience to provide this support. We can provide reassurance and perspective to you and your partner, make suggestions for labor progress and help with relaxation. We are independent and self employed. As your doulas, we are working for you, not your caregiver or hospital.

 

Services to be provided include the following:

• One in depth prenatal appointment with both Megan and Courtney.
• One prenatal virtual appointment with Megan and Courtney
• Assistance with writing your birth plan.
• Email and phone support throughout your pregnancy (during daytime hours; 9am-5pm)
• On call support from 38 weeks of pregnancy until the birth of your baby.
• Continuous support during labor and birth from one doula, based on the call schedule
• One postpartum visit, if possible both doulas will attend this visit.
• 2 weeks virtual postpartum support as needed, 9am-9pm

Prenatal visits will be scheduled before 38 weeks. One visit will be done virtually over zoom and the other will be at client’s home with masks. Any additional meetings will be virtual and discussed on a case by case basis.

 

Please call the doulas when you first start to notice signs of labor. It is important for you to call with regular updates during your early labor. This will allow us time to plan and for you to be in touch with your care provider. Once you are in active labor, a doula will be there to support you within two hours of the time you request in person support. After your birth your doula will remain with you until your family feels comfortable or for up to two hours. Initial breastfeeding support is also available if desired.

Should you require an emergency cesarean section birth, your doula will remain at the hospital and provide support throughout and after the birth. We will make every effort for your doula to be present in the operating room. It is up to the client to discuss cesarean procedures with their caregiver, understanding that the final decision is made by the hospital staff. In the event of a cesarean birth, all fees remain the same.

As doulas, we do NOT:

• Perform any medical or clinical tasks. We will provide only emotional and educational support and physical comfort.
• Speak for you. We will help you discuss concerns and can suggest options while encouraging you to pursue the birth you desire. Either you or your partner will need to communicate directly with medical staff regarding decisions about your birth.
• Make decisions for you. We can help provide you with information so you are able to make educated choices.

 
Failure to provide services:

We will make every effort to provide all services described here. Sometimes this is impossible (for example, with rapid labor, extreme weather, etc.)

In the unlikely event we are unable to attend your birth, we will provide you with a back up doula. There will not be any additional charge if this occurs.

It is up to the client to discuss policies and procedures regarding doulas with their care provider during pregnancy.

I/We have read this letter describing the doula’s services and agree that it reflects the discussion previously had with her and will adhere to policies detailed in this agreement. It is understood that services will only be rendered upon receipt of signed letter of agreement, confidentiality release and payment.

 

Responsibilities Of The Client And Client’s Partner:

Client agrees to inform her doctor or midwife that they have hired a birth doula. Client also agrees to keep in contact with doula after each doctor or midwife visit. Client will keep doula informed of client’s medical condition, including any test results so that the doula may answer any questions client may have. Client agrees to provide doula with a copy of her birth plan. She agrees to call doula with onset of labor and at least two hours before client would like doula to arrive at the predetermined birth site.

 

Release From Liability:

In entering a contract for doula services we acknowledge that during the performance period of this contract, services may be provided to me/us in my/our home, traveling to a medical facility and hospital. I/we understand that the aforementioned doula has a limited role pursuant to the descriptions of tasks outlined in the above-referenced contract, wherever services are provided to me/us. The aforementioned doula has not represented to us me/us that contracting for her services, guarantees in any way a risk free, emergency free labor and birth experience. I/we understand that my/our doula does not make medical or nursing decisions on my/our behalf, to include the decision when to seek medical care at a hospital or when labor support services are provided in my/our home. When services are provided in a medical facility, I/we acknowledge that my/our doula is not responsible for the performance of clinical tasks to include medical or nursing decisions regarding the inclusion or exclusion of treatments available to me/us and my/our baby.

Now, in the consideration of the above acknowledgments, I/we (both jointly and separately) on behalf of myself, ourselves, my/our heirs, administrators, personal representatives, executors and assigns to release and forever discharge my/our doula from all damages or causes of action, either law or in equity, which I/we have or acquire or which may accrue to me/us, my/our heirs, administrators, personal representatives, executors or assigns as a result of using the doula services of our aforementioned doula, I/we intend this to be a complete release and discharge her from all liability whatsoever.

Consent To Bill Insurance:

I, the undersigned, hereby certify and attest that I have sought doula care from Courtney Hoyle and Megan Bain. I therefore authorize the doula to release my private health information to the insurance company listed above for the purpose of determining and receiving benefits for medical bills.

I understand and acknowledge that the doula will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any amount of my medical bills not covered by my insurance policy or claims, and that I will be responsible for paying all deductibles, fees, co-payments, and co-insurance payments required.

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided below. Non-compliance or defaulting on payments may result in denial of service and/or a legal claim against me for non-payment.

If you authorize Courtney Hoyle and Megan Bain to use non-secure email and non-secure text messaging to communicate with you, please initial below.

In initialing above, you acknowledge that: - your “protected health information” (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and it’s implementing regulations) will not be secured by cell phone and email communication which are not considered confidential or secure, and where there is always a possibility that a third party may gain access; - you waive Courtney Hoyle and Megan Bain’s obligation to guarantee confidentiality with respect to correspondence via these means; - cell & email communication can become part of the permanent medical record.

The number of prenatal and postpartum visits covered is determined by your specific plan. The doula will inform the client when eligibility is checked, what is covered.

 

YOUR CHOICES

You have the right to tell us how to share your information: Please list who you would like us to share medical information with (friends, family, caregivers, etc.):

We will only share with other healthcare providers directly involved with your care and those listed above. In an emergency situation, where you cannot give us information on your preferences, we will share with others only if we believe it is in your best interest. We may also share your information when needed to lessen a serious or imminent threat to health or safety.