MEDICAID DOULA SUPPORT
This contract ("Contract") outlines the terms and conditions between the undersigned Client ("Client") and the Birth Doula ("Doula") for the provision of birth doula services. Both parties agree to the terms stated herein.
DOULA SERVICES
The Doula agrees to provide birth doula services, within the following doula scope of practice: emotional, physical, informational, and advocacy support.
The Client agrees Doula is not expected to provide medical advice, clinical care, or to speak to medical professionals on Client's behalf.
Services may be rendered during prenatal visit(s), birth support, or postpartum visit(s).
Client may choose to receive only prenatal visits (and no birth support). If so, this will have been communicated and agreed upon by both parties before signing of this contract
FEES & PAYMENT
The Client is responsible for ensuring active coverage with Insurance or Payer throughout the perinatal period. The Client agrees to notify Doula of any changes to their insurance coverage prior to any appointment or as soon as possible to avoid delays in claim processing
If Payer denies payment due to client’s failure to maintain coverage, submit required documentation, or meet eligibility requirements, the client will be responsible for the full payment of services as listed on Doula’s website, payable within 60 days of notice of denial.
Any services not covered by Payer can be purchased separately.
CANCELLATION POLICY
Cancellation Policy: Either party may cancel this contract, for any reason, at any time.
Conditions for Termination: Termination may occur at any time if either party breaches the terms of this contract. In order for termination to be in effect, the responsible party needs to notify the other party by writing.
DOULA’S AVAILABILITY
The Client may contact the Doula 24/7 when labor begins or waters break.
The Doula agrees to arrive within 2 hours of being requested for in-person support. Arrival time may vary for births located outside of Wichita, KS city limits.
Special note: on-call availability is not limited to a certain "window" within the Client's pregnancy. If there will be a period of time where the Doula will not be available (for example, planned travel to a destination more than 2 hours outside of Wichita, KS), Doula will make arrangements for a local backup doula to be on-call.
In the rare circumstances a back-up doula is not available, this will be communicated to Client as soon as possible. At that time, Client will be given the option to cancel this contract. If Client wishes to exercise this option, they must do so within 48 hours of being notified.
Backup Doula: Every effort will be made to provide a back up doula that is in-network with Payer if Client's Doula is unable to attend. If no in-network backup doula is available, Client will be responsible for paying $500 directly to backup doula that attends if requested by Client.
CLIENT EXPECTATIONS
Timely Communication: The Client agrees to inform the Doula promptly by phone call when they think they are in labor or their waters break. This allows the Doula time to make necessary arrangements and travel to the Client.
Accuracy of Information: The Client will provide accurate and complete medical information, as well as any pertinent updates throughout pregnancy.
Client acknowledges that Payer will only pay one doula for birth support each pregnancy, and Client agrees to not hire a second doula to perform this service.
Medical Provider: It is the Client’s responsibility to ensure the necessary arrangements are made to have a medical practitioner present at the birth.
BIRTH SUPPORT
Labor and Birth Support: The doula will support the Client during labor until 1-2 hours after the birth. The Doula may be unable to support labors lasting longer than 12 hours.
Breaks: Depending on the length of labor, the Doula may take short breaks for meals and rest.
CLIENT VISITS
Rescheduling: Visits may be rescheduled, depending on Doula and Client availability.
Number of Visits: Depending on availability, the number of visits listed in the package may not be able to be scheduled before the birth and the client may forfeit one or more of their visits.
MISSED BIRTH
Client understands that unforeseen circumstances, rapid birth, medical emergency, or other reason may prohibit Doula from arriving in time for Client's birth. Client agrees hold Doula harmless if this occurs.
OPTIONAL ADD-ON SERVICES:
Fees & Payment: Payer does not cover birth or fresh 48 photography services and is separate from doula services (as outlined above.) If Client would like the Doula to act in the additional role as a Photographer during their birth and bring their camera to capture, edit, and deliver professional images of the birth. Client will need to sign and pay for this separately. Client acknowledges that this is an optional service and even wiithout purchasing these services, they are still able to receive iPhone (or other equivalent) photos of the birth. If Client does not wish to purchase these services it will in no way hinder their birth support as covered by Insurance or Payer.
SIGNATURES
By signing, the Client agrees to the following: I authorize the release of any medical or other information necessary to process claims. I also request payment of government benefits either to myself or to the party who accepts assignment below. I authorize payment of medical benefits to the undersigned physician or supplier for services described above.
The Client understands that they may revoke this consent in writing at any time. However, revocation will not apply to services already rendered or claims already submitted.