Please note that this is a general template, and you should modify it to fit your specific circumstances. Consult with a legal professional to ensure that it complies with local laws and regulations.

Contract for Midwifery Services Agreement

[Your Midwifery Service Name]

This agreement is made between [Midwifery Service Name], represented by ________________________, CPM, and the prospective client(s) _______________________________________________________, who agree to the following terms and conditions for the provision of services by [Midwifery Service Name]:

Statement of Fees

The fee for [Midwifery Service Name] Midwifery Service is $_________. For this amount, you receive:

• A full physical exam
• A full schedule of prenatal visits: once monthly until 28 weeks; twice monthly until 36 weeks; once weekly until 40 weeks; more visits as required past 40 weeks
• A Home Visit between 36-38 weeks
• Attendance by a Certified Professional Midwife and an assistant at your labor & delivery
• Use of the labor tub
• [Number] postpartum home visits (more if necessary)
• Birth Certificate paperwork
• Office visits at 6 and 12 weeks
• Professional and timely transfer of care with tailored doula care, as needed
• Any additional visits necessary during the period of coverage
• Use of our lending library
• Unlimited phone availability
• Labs, supplements, herbs, birth kit, birth pool supplies, vitamin K, newborn metabolic screen not included

Retainer Fee

A NON-REFUNDABLE retainer is required at your first visit ($__________ of which is non-refundable). We limit the number of clients we care for in our practice. Therefore, your retainer serves to reserve a place in our care. If you transfer care (for any reason) prior to the birth of your baby, $__________ will be considered non-refundable and will not apply towards any itemization of your care. However, should itemization be required after the birth of your baby, we will apply the entire retainer towards your itemized bill.

The total retainer amount required at your first visit is determined by when your care begins:

• In your 1st trimester (up to 12 weeks) $__________
• In your 2nd trimester (up to 27 weeks) $__________
• In your 3rd trimester (28 weeks or beyond) $__________

Late Fees & Penalties

• Returned Check Fee is $5.00 and up.
• Additional charges may apply when a contract is not paid in full by the final due date:
  • 1 – 30 days late - $50 fee
  • More than 30 days late - $100 fee
  • Every subsequent 30-day period with an outstanding balance – 10% late fee on remaining balance

Insurance

Many insurance companies now cover all or a portion of homebirth costs. If you have insurance that will cover midwife-attended homebirth, our biller will bill your carrier after the baby is born for the usual and customary charges. They may choose to cover the cost of your birth, minus any deductible, co-pay, or out-of-plan provider deduction, but we cannot guarantee this. Once payment is received from the insurance company, your fee will be reimbursed to you. You are responsible for all co-pays and deductibles. A fee of $25 will be charged to you to obtain a Verification of Benefits (VOB) from your insurance provider if you plan to seek insurance reimbursement, and an 8% service fee will be charged by our biller. If any abnormal conditions arise during the prenatal period necessitating the termination of these services before the 37th gestational week, the fee to your insurance company will be prorated based upon the length of pregnancy and services provided.

Transfer of Care

There may develop various complications which the midwife and/or the client might feel contraindicate a safe out-of-hospital birth. The midwife will appropriately arrange for transfer of your care with one of several local obstetricians or the obstetrician of your choice. In an emergency, your midwife will transfer with you to the nearest hospital. If you transfer late in pregnancy, or during labor, your midwife will accompany you during your labor and birth in the hospital as your doula. Postpartum care will continue for 12 weeks after the baby is born unless you opt out. Transfer of care at 36 weeks or more, or during labor and birth, does not constitute grounds for a refund of payments made.

Refunds

Refunds and insurance billing for transfer of care before 36 weeks will be handled on a case-by-case basis. All charges accrued from hospital, doctor, or other medical charges will be your responsibility and are not included in this financial agreement.

Missed Birth – Precipitous Labor

Rarely, a birth is missed by the midwife for reasons out of her control. These may include, but are not limited to:

• Your labor and birth happen so rapidly that your midwife may be unable to make the delivery.
• The midwife was not called by the family during the labor and birth.
• Unfavorable weather conditions that make the roads impassable or difficult to traverse.
• Birthing in a location that is of a great distance from your midwife.

Please rest assured that every attempt will be made to attend your birth once the midwife is called in. If circumstances arise that prohibit your midwife from attending your birth, the fee for services will not be reimbursed. Your midwife will guide you over the phone while traveling to you, arrive at your birthplace as soon as possible, and provide your family with immediate postpartum care, and the standard postpartum care described in this contract. Special circumstances will be evaluated on a case-by-case basis.

Student Midwives

Your midwife will inform you if she has a student that is assisting and learning with her. All students must be supervised with a midwife present. You have the right to refuse any care performed by the student and may inform the midwife if you prefer no students at your birth.

Financial Agreement for Midwifery Care and Payment Options (Please initial)

__________ I/We agree to pay the fee of $_________ for homebirth midwifery services provided by [Midwifery Service Name] and staff. This financial agreement covers the midwifery care as outlined above, and I/we have had an opportunity to discuss my/our options before signing this document.

_________ I/we agree to pay this amount according to the following payment schedule:

1. Payment of $_________ within the first three visits:
   • Initial Visit - $_________ Retainer Fee
   • 2 payments of $_________ at the following two visits

OR

• Initial Visit - $_________ Retainer Fee
• 2 payments of $_________ at the following two visits

1. _____ Bi-monthly payments of ___________ on _____________________ date of the month
2. _____ Monthly payments of ____________ on _________________ date of the month
3. _____ Alternate payment plan as outlined below:

All payments will be applied to the agreed-upon fee balance.

________ I/we understand that we have several options to pay:

• Square Up (Credit/Debit)
• Paypal
• Square Cash (email wire)
• Cash
• Check
• Money Order
• Venmo

________ I/we understand that the agreed-upon fee must be paid in full by TWO WEEKS BEFORE our due date. If I/we are truly unable to make full payment by this date, I/we agree to discuss this matter with the midwife. If a payment is missed, I/we will be asked to submit post-dated checks for the remaining balance. I/we understand that the agreed-upon fee may be subject to change if the terms of the contract are not upheld by the client.

________ I/we have read and understand the terms of this contract and financial agreement. Today’s Date: _________________

Client Name (please print) ____________________________________________________________________________________________________

Client Signature ________________________________________________________________________________________________________________

Other Responsible Party _______________________________________________________________________________________________________

Other Responsible Party Signature ____________________________________________________________________________________________

Midwife Signature _____________________________________________________________________________________________________________

Instagram Post Made by Nicole Kristensen, Full Spectrum Doula from New York

Link 1: How Bornbir Works.

Link 2: Midwife Requests Near Your Zip or Postal Code.