Financial Arrangements Birthing Center - $6575. What is Included

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1 Financial Arrangements Birthing Center - $6575 The fee for comprehensive maternity care services with The Birth Place/ Commonsense Childbirth Inc. has been carefully determined to meet the needs of providing a quality service. Jennie Joseph and her staff bring many years of combined expertise to provide you with a safe and rewarding birth experience. We have tried to make financial arrangements as simple as possible. If there is anything that you do not understand or have questions about, please contact the office. If you are self-pay a cash discount of $5952 will be offered and may be paid by cash, check, MasterCard, Visa or Discover. If you are self-pay, payment is expected at the time of service according to your self-determined payment plan including a deposit of $250 at your first visit and a minimum payment of $125 each subsequent visit. According to your agreed upon payment plan, you must pay in full by your 36th week of pregnancy unless prior arrangements have been made. (Please Initial ). Please note that if you are not paid in full when labor starts the midwife will not attend your delivery and your care will be transferred to the hospital where you will incur additional fees. What is Included The fee for the Birthing Center Package includes - all routine prenatal and postpartum lab work drawn or collected by our center staff. (Labs charge independent fees, including draw fees, if you go to one of the labs for your blood work). Any additional labs are charged to you at time of service* 13 prenatal and 2 postpartum visits, including 24 hour access to midwives and staff for emergencies and labor all labor and delivery services at The Birth Place, birth center midwifery management care of mother and baby during labor, delivery newborn care and comprehensive examination; pediatricians report; birth certificate and social security number filing required state tests and medications for newborn post-delivery recovery and monitoring of mother and baby use of the facility and equipment, and medical supplies water birth management, set up and equipment *SELF PAY clients please note: - This package does not include any additional or unusual lab work (such as RH negative testing, Rhogam injection, post-infection cultures or blood work, tests for thyroid etc), procedures such as sonograms/ultrasounds or any physician

2 consultations or hospital fees that may be necessary. Lactation services for problems considered outside of normal/routine postpartum care are not included. - The newborn metabolic screening (PKU) is an additional $40 due at the time of postpartum visit or is available at your pediatricians office. - A list of non-medical supplies needed for your delivery will be provided for you. *INSURED and MEDICAID clients please note: - The newborn metabolic screening (PKU) is an additional $40 due at the time of postpartum visit and is not covered by your insurance for our office. It may be done through your pediatricians office. - A list of non-medical supplies needed for delivery will be provided for you. - Fees for all birth center services will be billed to the insurance as a comprehensive global bill once baby is born. Labs will be billed to insurance at the time services are rendered. Changing Insurance or Payment Status If you change insurance or Medicaid, or go from self-pay to insurance/medicaid, you will be responsible for the payment of services rendered prior to the insurance effective change date. If you acquire insurance but were previously self pay, we will not back bill for services rendered and you will be responsible for payment of services rendered up to the date your new insurance/medicaid has been approved and verified by us. If your Medicaid HMO is switched inadvertently please notify us immediately to avoid being responsible for ongoing fees. (Please Initial ). A new financial agreement will be established any time a change in insurance is made. Should insurance coverage be denied at any time because of a change of insurance without prior notification to The Birth Place, the maximum out of pocket price for services rendered will be the responsibility of the patient, plus any additional lab work or other services provided by the center. (Please Initial ). The Birth Place must be notified of any changes to the status of the insurance coverage or required pre certifications or pre-authorizations needed by your insurance policy. We encourage you to call your insurance about your coverage. Medicaid If you apply for Medicaid or have a Medicaid HMO and choose a birth center birth, you will be required to pay for your prenatal care until your Medicaid is active, and notification of pre-authorization for pregnancy and birth is also active through the Medicaid HMO. For the purposes of this contract the date we are notified is the date we will consider your Medicaid active, even if Medicaid gives you retroactive coverage. We do not accept retroactive Medicaid for birth center clients. All Medicaid clients MUST choose a Medicaid HMO per Florida guidelines and you are responsible for establishing and maintaining coverage. Should your Medicaid become inactive at any

3 point during your care, you will be responsible for payment for services rendered to you during that time. Insurance Claims The Birth Place agrees to assist in filing claims to your insurance via our off-site billing service Larsen Billing Service. This is done as a courtesy and is NOT required by providers. We agree to do our best to get the insurance to cover your claim based on your policy. For in-network insurance companies, we must cap the estimated out of pocket amount at the contracted allowable amount for that insurance company. If the insurance pays less than expected, the difference is the responsibility of the client, up to the contracted price. Should we have difficulty collecting payment from the insurance company, the balance of the complete agreed upon package price is the responsibility of the client and is expected to be made by twelve (12) weeks postpartum regardless of insurance coverage or estimated out of pocket amount. (Please Initial ). The estimated out-of-pocket amount is equal to the expected amount not covered by insurance and is based on the contracted allowable amount with the insurance company or our self pay price. This is an estimate only. We do not guarantee what amount the insurance will pay toward your claim. This is subject to your deductible, co-insurance and individual plan allowances. You are responsible for any amount not covered by insurance. (Please Initial ). Insurance Contract Year This contract is for the current year. If your insurance term and pregnancy crosses over into next year, a new financial contract may be needed, and you may have additional out of pocket costs due to additional co-pay and deductible requirements beginning in a new year. We will collect your deductible, co pays and co-insurance in the amount expected for the year that you are due. We will bill the insurance as a comprehensive global bill once baby is born. This mean that you will be paying those amount in the current term, to be applied to your estimated balance due for your birth, as we collect your estimated out of pocket cost IN ADVANCE. If you have met your deductible for the current year due to services outside of this pregnancy but do not have your baby until after the start of a new insurance term, you may be responsible for the current term deductible/copay/coinsurance. For example, your insurance term ends December 31 st but you have your baby January 1 st of the next year - however, any deductibles and copays paid in advance in the prior term will be credited towards the current term in which you deliver.

4 Reimbursement Should a condition arise during pregnancy which requires a referral to a doctor or hospital for continued care, self pay clients will receive reimbursement of any advance payments made towards the delivery fee and a final bill reflecting a fee for each individual service received. Refunds can take up to 8 weeks or longer, depending on insurance billing cycles. If we receive payment from an appeal, we will refund any monies owed to you. Once payment is made by the insurance company, any payment made by the client where the total paid is over the contracted price will be refunded. If you are admitted directly to the hospital during labor, or for delivery, your hospital bill is separate and additional, and will be your responsibility. After 37 weeks, and if there is an admission to the birth center, with a subsequent midwifery managed transfer to the hospital for delivery with attendant care, there will be NO reimbursement of pre-paid fees for self-pay clients.(please Initial ). Assignment of Benefits: I acknowledge that I am legally responsible for all charges in connection with the midwifery care and treatment provided by The Birth Place/Commonsense Childbirth Inc. I assign and authorize payments to be made directly to The Birth Place/Commonsense Childbirth Inc. from my insurance carrier, including Medicaid. If payment is denied by my insurance carrier, I agree to pay the balance due, in accordance of the contract above. (Please Initial ). I, understand and agree to the terms of this financial agreement with The Birth Place/Commonsense Childbirth Inc. Signature: Name: Witness: Name:

5 Payment Guidelines - please create your own payment plan Self-pay package clients; insurance co-pays and deductibles; additional payments 1. Payments must be timely and in accordance with the payment schedule that you choose. Any exceptions must be arranged and approved in writing two weeks in advance of when payment is due. 2. You must mail or have someone deliver your payment so it will arrive on time, according to your pre-arranged schedule. 3. Postdated checks are not accepted. 4. There is a service charge on all returned checks. If there is more than one returned check you will need to pay in cash or money order for remaining payments. 5. Failure to make a timely payment will result in a delay in your subsequent prenatal visit(s) and could ultimately jeopardize your birth center birthing experience. 6. Failure to complete payments by 36 weeks of pregnancy (unless other arrangements have been made) will result in discharge from the practice and a reimbursement of any over payment, if applicable, will be made. 7. We would appreciate hearing from you as early as possible if you anticipate any difficulty with payment so that other arrangements can be made. 8. We accept MasterCard, Visa and Discover for your convenience and can arrange to withdraw your scheduled payments from your credit card or bank account.

6 Payment Plan Name Please outline your intended payment plan below thank you. Total Amount Due: 36 weeks by / / Payment # 1 $ Payment # 2 $ Payment # 3 $ Payment # 4 $ Payment # 5 $ Payment # 6 $ Payment # 7 $ Payment # 8 $ Signature: Accepted by: