Safe Journey's Midwifery, LLC

Welcome to Safe Journey’s Midwifery! We look forward to assisting you in delivery of your infant and thank you for choosing our service. I do not provide insurance billing. Therefore, if you have insurance I will be able to provide you with an itemized bill to enable you to file your claim for reimbursement for your care.

Client-Midwife Contract

Safe Journey’s Midwifery (also referred to as Terina/Terina L. Knarr, CNM in this contract) and_______________________________________agree to the following terms and conditions for theprovision of midwifery services.

Midwife

The owner of Safe Journey’s Midwifery, Terina L. Knarr, CNM, is licensed by the State of Missouri to practice independent midwifery and acts as an Advanced Practice Nurse. She has received formal midwifery education and obtained a Master’s Degree from the Frontier School of Midwifery and Family Nursing and clinical training as outlined by Missouri Laws and Statutes. 

Services Provided

Safe Journey’s Midwifery, Terina L. Knarr, CNM provides standard prenatal, labor, post birth care and well newborn assessment and care (up to 28 days of life for newborns).  The services included in your fees are as follows:

• Midwife and birth attendant(s) of midwife’s choice and training
• Pregnancy testing
• Nutritional counseling
• Prenatal care to include antenatal and postpartum care as follows: once monthly until 36 weeks, then at 38 weeks and then weekly until delivery-all visits in your home. At 42 weeks your risk for complications increases and subsequently disqualifies clients for a homebirth. The risks associated with post dates include but are not limited to: stillbirth, postpartum hemorrhage, shoulder dystocia related to a possibly large sized infant and death of mother due to complications. We (client and Terina L. Knarr, CNM) will discuss those choices/decisions should the client reach 42 weeks.
• Postpartum visits in your home for mom and baby within 24-72 hours after delivery to include Newborn Metabolic Screening.  Additional visits at 1 week, 2 weeks and a postpartum check up at  6-8 weeks after delivery to include a postpartum pap smear if you desire and any discussion/decision you may have regarding birth control.
• Nutritional counseling
• Childbirth preparation and educational teaching. However, it is highly recommended that you attend childbirth classes especially if this is your first pregnancy.
• Labor support and homebirth
• Newborn examination and care up to 28 days of life. However, it is YOUR responsibility to make arrangements for long term pediatric/physician care for your infant. This is to be done prior to your infants’ arrival should there be any illness or need to seek care for your infant in urgent/emergent situations.
• Breastfeeding education and support
• Suturing, if needed for 1^st and 2^nd degree tears
• 24 hour availability of me throughout your care
• Any additional visits necessary during your period of coverage at a cost of $100 per visit not included in the schedule.
• Electronic, phone or postal communication
• Filling out of any needed forms, as allowed/required by your employer
• Any referrals or transfer of care as we (client and midwife) agree
• Newborn Metabolic Screening per state guidelines (Additional $65.00), Vitamin K prophylaxis and eye medication prophylaxis.  (I do not provide vaccinations. You will have to obtain any and all vaccines from your chosen pediatrician/family practitioner or your local health department)
• Ordering of clinical laboratory testing, ultrasounds and medications
• Rh Antibody Testing & RhoGAM Treatment: In the case of an Rh-negative mother and an Rh-positive baby to include cord samples lab work to determine the baby’s blood type. RhoGAM administration is an extra charge and is determined by the cost of the medication at the time of use.

Safe Journey’s Midwifery DO NOT provide the following services:

• Ultrasound (if one is desired or needed I will write a prescription for you to obtain this at the nearest facility at your expense)
• Circumcision
• Prescribing or giving of analgesic drugs or narcotics before, during or after the birth
• Delivery by forceps or vacuum
• Suturing of perineal tissue with a 3^rd or 4^th degree laceration
• Newborn Hearing Screening-State Mandated
• Immunizations
• Hospital, birth center or cesarean deliveries other than birth support;  Safe Journey’s Midwifery  is NOT responsible for any incurred expenses that occur as the result of transport
• Insurance submission of claims

Clients will provide and pay for the following:

• A Safe Journey’s Midwifery Birth Kit, available at www.preciousarrows.com, and items on the supply list in the Welcome Packet.
• Laboratory testing at clients’ request that are not part of the OB Panel or normally needed for good prenatal care in healthy, normal pregnant woman. I.E.: amniocentesis, genetic screenings and any other tests recommended by Terina Knarr, CNM or requested by the client.
• Initial Newborn Metabolic Screen ($65.00 or determined by the state)
• Ultrasounds at the clients’ chosen facility or can be arranged at a reduced cost through my clinic.
• Newborn Hearing Screen
• Prescriptions & Non-Prescription medications or herbal supplements needed for the mother and/or infant related to the present pregnancy and postpartum care
• Emergency expenses that may include transportation, emergency room and physician expenses, surgery and medications; or any standard hospital, clinical, physician, nursing, or doula expenses related to the present pregnancy & postpartum care; or referrals to any other providers should complications and/or transport arises
• Visits outside of the “Routine Schedule of Visits” initiated at the client’s request are billed at a rate of $100/visit
• Birth Tubs/Pools

Initial Consultation

A free initial consultation is provided to determine your eligibility for midwifery care/home birth. I will discuss with you your general health; risks of childbirth and home birth to the mom and baby; management of complications in and out-of-hospital setting; your decision and expectations for midwifery care and home birth; a plan for arrangements for back up medical care and/or transport should the need occur and provide ample opportunity for prospective clients to ask question. Safe Journey’s Midwifery encourages the client to do research and prepare a list of questions prior to our initial consultation.

In the selection and treatment of clients, I rely on the medical history and information provided by the client. The client agrees that such information will be complete and accurate to the best of her knowledge. The client understands that certain aspects of her health may preclude her from midwifery care and/or home birth.

Transfer of Care

The client understands that certain complications may develop during pregnancy, birth and/or the postpartum period that require transfer of care to a medical provider and/or facility. The midwife will do her best to provide adequate information in a timely manner in the event of a transfer of care. The client agrees when signing this contract that Safe Journey’s Midwifery may release a copy of your prenatal  records, including labs, ultrasound reports and course of care, as applicable, should an emergent need arise.

Use of Medical Records

The client authorizes Safe Journey’s Midwifery(Terina L. Knarr, CNM) to have full access to medical records for clinical management, research, statistical purposes, provided her privacy is reasonably protected in accordance with HIPPA laws and regulations. Participation In out-of-hospital midwifery statistical projects occurs only after consent of the client, with exception of peer review and review by my collaborating physician(s) in accordance with the state of Missouri laws and guidelines. I also understand that birth attendants and other employees of Safe Journey’s Midwifery may have access to my records when charting or filing.

Consent to Treatment

The client gives her consent to safe Journey’s Midwifery and Terina L. Knarr, CNM, to care for and treat her during the course of her pregnancy, birth until conclusion of care at 6-8 weeks postpartum. This contract will remain in force until the conclusion of care; the client informs Safe Journey’s Midwifery of her intentions to seek care elsewhere or it is in the clients’ best interest medically to be referred for care due to unforeseen complications. The client agrees to assume full personal and legal responsibility for her decision to have an out-of-hospital birth and to prepare for the same.

Informed Choice

The client has been informed of the credentials of Terina L. Knarr, CNM and her scope of practice; the risks and benefits of an out-of-hospital birth and the limitations of midwifery care. The client has had ample opportunity to ask any and all questions pertaining to midwifery care. This is outlined throughout this contract for midwifery services.

Release of Liability

Before signing this agreement, I (also referred to as client, we, I, they, us or her) have had an opportunity to discuss Safe Journey’s Midwifery care and homebirth  with my spouse, partner or parent, if that parent is a legal guardian; with a medical care provider or other knowledgeable person, if needed, and with Terina and ask her questions. Terina Knarr, CNM has discussed her limitations as a midwife; model of care as well as her philosophy with me/us. Terina Knarr, CNM has not represented to the clients that agreeing to her services guarantees in any way a risk free or emergency free labor and birth experience. We have chosen to have a home birth. We have asked Terina Knarr, CNM to assist us in our home birth. The clients (jointly and separately), the clients’ heirs/family, administrators, personal representative, executors and assigns, release and forever discharge Terina Knarr, CNM, Safe Journey’s Midwifery, assistants and collaborating physicians, from all damages or of action, either at law or in equity, which the clients may have or acquire or which may accrue to the clients or the clients heirs, administrators, personal representatives, executors or assigns as a result of using the midwifery services of Terina Knarr, CNM. The clients intend this to be a complete release and discharge from all liability whatsoever. The clients are signing a complete release and bar to any claims which the clients have or believe the clients may have resulting from our agreement for midwifery services. I/We hereby release Terina Knarr, CNM, Safe Journey’s Midwifery, her assistants and collaborating physician(s) from all complications that may arise during the course of my pregnancy, birth or postpartum as a result of my decisions and my choice to birth my child at home. I/We acknowledge that Terina Knarr, CNM is an independent provider. I/We further acknowledge that I/We have had an opportunity to have any questions answered regarding the benefits and risks specific to homebirth.

Schedule of fees

All fees must be paid in full by the scheduled payment plan agreed to regardless of gestational age at entry to care. I require a non-refundable $500.00 deposit due at the signing of this contract. All payments may be made to me, Terina Knarr, CNM (or Safe Journey’s Midwifery) by cash, check or bank issued money order. Payments may be mailed to me at: 9187 Hwy 17, Bucyrus, Mo. 65444.  All returned checks subject to a $25.00 returned check fee. You may want to take advantage of our “Timely Pay Rate” schedule.

A deposit of $500.00 is due upon returning the signed contract. Ideally, clients must return their contract by their 2^nd visit. Without this payment, a woman will not be considered a client of Safe Journey’s Midwifery and no spot will be held for her eventual labor and birth. Due to the range of payments options available, there is a suggested timeline for making payments outlined below. These are just suggestions as clients may make smaller or larger payments as long as they are paid in full according to the payment option chosen.

If you desire birth services only, the fee is $2100.00 due by the 37^th week. If you desire birth and postpartum/newborn services only, the fee is $2500.00 due by the 37^th week. The above fees include the $500.00 non-refundable fee.

(PLEASE INITIAL NEXT TO YOUR PAYMENT CHOICE)

In cases of financial hardship, clients may request a revision to their payment plan or barter for partial services. Safe Journey’s Midwifery, Terina Knarr, CNM, reserves the right to decline to alter any existing agreements. The level of care will not be compromised because of any kind of discount.

*****If you desire any payments to be covered by your insurance, I will assist with filling out any forms necessary. Please keep in mind, that YOU, the client are still responsible for the difference regardless of insurance coverage, since midwifery care is significantly cheaper than hospital care. I also CANNOT guarantee that any insurance will cover midwifery/homebirth services.

Transfer of care/Refunds

Once the client signs this contract and remits the deposit of $500, prenatal care begins by Safe Journey’s Midwifery, Terina Knarr, CNM and a spot is secured on the roster for the upcoming birth. If client is referred to another care provider or discontinues their relationship with Safe Journey’s, Terina Knarr, CNM, at any point, for any reason-NO REFUND WILL BE GIVEN OF PAYMENTS MADE UP TO THAT POINT. Reasons for discontinuation that would not result in a refund include, but are not limited to: moving, change of mind, miscarriage, changing practices or missing scheduled visits for any reason. When client goes into labor and the midwife and/or any birthing attendants arrive to attend the labor, regardless of outcome and final place of delivery, NO REFUND WILL BE GIVEN. If it is a rapid birth or if Safe Journey’s Midwifery, Terina Knarr, CNM, receives delayed notification and misses the birth, or if Safe Journey’s Midwifery, Terina Knarr, CNM, is not present at the birth for reasons beyond anyone’s control-NO REFUND WILL BE GIVEN. However, postpartum and newborn care will be given as agreed. If during labor, delivery or postpartum care at any time, you are transferred to a medical facility, the midwife will continue to provide labor support and lactation assistance, if you desire and follow up postpartum/newborn care as previously agreed.

***The only way in which a refund may be given is if a client pays ahead of schedule. For example, the client chooses and pays in full the 36 week option by 24 weeks and care is discontinued at some point prior to 36 weeks. Then a refund will be issued minus all care given up to the pay rate schedule given. The amount of any refund varies by the pay rate schedule chosen by the client, how many visits were made, what tests were conducted, what services were given by Safe Journey’s Midwifery and the exact amount of money paid by the client. Not only will your prenatal care have been given but the midwife and assistant is on call 24/7 for the client and spaces in our calendars have been set aside for the prenatal visits, your birth and postpartum visits; thus precluding the birth team from engaging other clients. Your refund will not include the $500.00 deposit as well.

In the event of a delivery prior to 37 weeks and a homebirth is not recommended or if the client/couple is referred to the hospital prior to the onset of labor, Safe Journey’s Midwifery , Terina Knarr, CNM, agrees to refund the client as outlined above, minus the $500.00 non-refundable deposit.

Safe Journey’s Midwifery, Terina Knarr, CNM, reserves the right to terminate services and not attend the birth if full payment is not received as agreed above or if prior arrangements have not been made. In the event payment is not made and Terina Knarr, CNM, withdraws from providing care, she will immediately inform the client/couple in writing, in person and/or by phone. She will also return any portion of the birth fee which has been paid except the non-refundable deposit of $500.00 and a $100.00 per each prenatal visit and $100.00 for prental labs thus far and an additional $100/week for any balance due beyond the due date until account balance is satisfied.

The client has the right to terminate this contract at any time, for any reason and receive a refund as outlined above. The client agrees in the event that they chose to terminate this contract for any reason, that they will notify Safe Journey’s Midwifery, Terina Knarr, CNM, by phone, by email, or by regular postal service (with return receipt notice). If you are not satisfied with my care at anytime I would appreciate the opportunity to resolve any matters within my company before formal complaints are made. However, the client understands they have the right to lodge formal complaints.

Safe Journey’s Midwifery, Terina Knarr, CNM, further reserves the right to decline further care in the event of non-payment within agreed upon terms, Terina Knarr, CNM’s assessment of client medical or psychological condition(s), or because of noncompliant/uncooperative actions on the part of one parent or both.

I/We have read the above contract and agree to contract Safe Journeys Midwifery, Terina Knarr, CNM, for the services stated within this agreement. I/We accept the full financial obligation of all services rendered. I/We do hereby understand and accept all information, terms and conditions as laid out herein. I/We execute this contract voluntarily and with full knowledge of its significance and ramifications.

___________________________________________   ______Terina Knarr, CNM___________________

Terina Knarr, CNM                                                                  

_________________________________________    _________________________________________

Client #1 (Mother)                                                                             Client #1 printed name

_________________________________________   _________________________________________

Client #2 (Spouse, significant other, partner)                        Client #2 printed name

(if applicable)

________________________________________    _________________________________________

Legal Guardian (if applicable)                                                     Legal Guardian printed name



Additional Details

Once you decide to use Safe Journey's Midwifery, LLC and actual copy of a contract will be printed off, signed by you and your partner and placed in your chart.

Vaginal Birth After Cesarean?

An additional consent form is required after consultation and determination of appropriateness for a HBAC.