Patient Registration Packet

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Welcome to Our Birthing Center! We are excited and honored that you have chosen us to partner with you for this momentous life event. Please make sure that you have completed all 4 steps below required to complete your registration.

Step 1: Complete a Verification of Benefits to ensure that your financial responsibilities will be covered by your insurance company.

Step 2: Complete pages 2 – 5 of the attached packet with the following information: SECTION I – General Information SECTION II ‐ Mother’s Information SECTION III – Spouse’s Demographics SECTION IV – Baby’s Information Please note that Section II and III is information requested by the State of New Jersey’s Vital Information Platform used to maintain statistics and issue the baby’s Birth Certificate.

Step 3: Sign attached Consent Forms ‐ Patient Rights and Responsibilities – page 6

‐ Terms of Enrollment General Statement – page 7

‐ Consent Form – pages 8 & 9

‐ Transfer Guidelines – page 10

‐ Patient Certification– page 11

‐ Facility Out‐Of‐Network Disclosure – page 12

Step 4: Sign HIPAA (privacy) Agreement

Completed forms along with a copy of photo ID should be emailed to [email protected]

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SECTION I – GENERAL INFORMATION Date: ______

PATIENT INFORMATION Patient Legal Name: ______First Middle Last Preferred to be called: ______Maiden Name: ______Mother’s Place of Birth (State/Country): ______Mother’s Residence Address: ______Street Apt. City/Town State Zip Mother’s Residence County: ______Mother’s Residence Municipality: ______(The Municipality is the governing body that collects property taxes for your residence. The municipality can vary from your mailing address and often does. If you are uncertain of the municipality you reside in, you can easily confirm this by calling the municipal building for the municipality you think you are in and ask if your address is within their boundaries.)

Is Mother’s Residence within City Limits? □ Yes □ No Residing at current address for how long (months/years)? ______Is Mother’s Mailing Address the same as Residence? □ Yes □ No. If No, provide mailing address: ______Cell Phone: (______) ______‐______Home Phone: (______) ______‐______Email Address: ______Social Security: ______‐____‐______Date of Birth: _____/____/______Age: ______Month Day Year Estimated Due Date: ______LMP (Last Menstrual Period): ______First Pregnancy: □ Yes □ No Children: ______Mother’s Marital Status: □ Married □ Living with Partner □ Separated □ Widowed □ Divorced □ Single Midwife /Physician /Practice you are seeing: ______Doula you are using: ______Who can we thank for referring you to Our Birthing Center? ______

FATHER / SPOUSE / PARTNER CONTACT INFORMATION Name: ______Phone: (______) ______‐______Email: ______

SECONDARY EMERGENCY CONTACT INFORMATION Name: ______Phone: (______) ______‐______Relationship: ______Comments: ______

FINANCIAL INFORMATION Principal Source of Payment for Facility Fee: □ Commercial Insurance □ Self‐Pay □ Health Share □ Tri Care Insurance Carrier: ______Member ID#: ______Policy Holder: □ Patient □ Father/Spouse/Partner □ Other (list name & relationship): ______

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SECTION II – MOTHER’S INFORMATION

MOTHER’S MEDICAL HISTORY Did Mother participate in WIC during pregnancy? □ Yes □ No If yes, what was Mother’s WIC number? ______Number of Previous Live Births ______Number of previous live births now living ______Number of previous live births now dead ______Date of last live birth ______Number of other pregnancy outcomes ______Date of last other pregnancy outcome ______Number of Previous Induced Terminations (abortions) _____ Number of Previous Fetal Deaths ______Does this mother have any children diagnosed with Autism Spectrum Disorder? □ Yes □ No Mother’s Height: ______Pre‐Pregnancy weight (lbs): ______BMI: ______Feet inches Date of first Prenatal Care visit ______Did mother take Prenatal vitamins? □ Yes □ No When did mother take prenatal vitamins? (check all that apply) □ Pre‐Pregnancy □ 1st Trimester □ 2nd Trimester □ 3rd Trimester

Maternal Risk Factors NCHS (check all that apply) □ Diabetes If yes, □ Prepregnancy (diagnosis prior to this pregnancy). If yes, Insulin Dependant? □ Yes □ No □ Gestaonal (diagnosis in this pregnancy). If yes, Insulin Dependant? □ Yes □ No □ Hypertension If yes, □ Prepregnancy (chronic) □ Gestational (PIH, preeclampsia) □ Eclampsia □ Other previous poor pregnancy outcome (includes perinatal death, small for gestational age/intrauterine growth restricted birth). □ Previous preterm birth □ Pregnancy resulted from Inferlity treatment. If yes, □ Fertility‐enhancing drugs taken by the mother □ Ferlity‐enhancing drugs taken by the father □ Inseminaon □ Assisted reproducve technology (IVF, GIFT, ZIFT) □ Mother had a previous Cesarean delivery. If yes, how many? _____ □ None of the above Maternal Risk Factor Other (check all that apply) □ Anemia (Hct,30/ Hgb ,10Gm/dl) □ Cardiac Disease (“heart condion”) □ Family history of congenital anomalies or syndromes □ Obesity □ Seizures □ Trauma □ Asthma, history □ Cystic Fibrosis □ Liver disease □ Phlebitis/DVT □ Sickle cell disease □ Tuberculosis □ Blood Dyscrasia □ Depression/Mental illness □ Lupus □ Renal disease □ Sickle cell trait □ Uterine abnormality □ Cancer □ Epilepsy/seizure disorder □ Neurologic condition □ Rh sensitization □ Thyroid disease □ None of the above Mother’s Infections ‐ NCHS (check all that apply) □ Chlamydia □ Syphilis □ Hepatitis C □ Hepatitis B □ Gonorrhea □ Trauma □ None of the above Mother’s Infections ‐ Other (check all that apply) □ CMV □ Toxoplasmosis □ Listeria □ Parvovirus □ HPV □ Lyme Disease □ Group B Streptococcus (GBS) □ Varicella Zoster □ Malaria □ Rubella □ Influenza □ None of the above □ Hep A □ West Nile Virus □ Unknown Did mother have a fever that lasted more than 24 hours? □ Yes □ No If yes, check all that apply □ 1st Trimester □ 2nd Trimester □ 3rd Trimester

Tobacco Use Did mother smoke cigarettes before or during pregnancy? □ Yes □ No # of Cigarettes per day # of Packs per day Three months before pregnancy ______First Trimester ______Second Trimester ______Third Trimester ______

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Drug Use ‐ In the month before mother knew she was pregnant, how much marijuana did she smoke? □ Any □ None ‐ In the month before mother knew she was pregnant, about how many days a week did she use any drug such as marijuana, cocaine or opioids? □ Every Day □ 3 to 6 Days a Week □ 1 or 2 Days a Week □ Less than 1 Day a Week □ Did Not Use Drugs

Alcohol Use ‐ Did mother ever drink wine/beer/liquor? □ Yes □ No ‐ In the month before mother knew she was pregnant, how much wine/beer/liquor did mother drink? □ Any □ None ‐ In the month before mother knew she was pregnant, about how many days a week did she drink wine/beer/liquor? □ Every Day □ 3 to 6 Days a Week □ 1 or 2 Days a Week □ Less than 1 Day a Week □ Did Not Drink

Environmental Exposure (Check all that apply): □ Lead (home built before 1978) □ Tobacco (2nd or 3rd hand smoke) □ Viral (birds or cats in home) □ None of the Above

Mental Health & Substance abuse Risk Assessment □ Did either of your parents have a problem with drugs or alcohol? □ Does your partner have a problem with drugs or alcohol? □ Have you ever felt manipulated by your partner? □ Have you ever felt out of control or hopeless? □ Over the past 2 weeks have you felt down, depressed or hopeless? □ Over the past 2 weeks have you felt lile interest or pleasure in doing things? □ None of the Above

MOTHER’S DEMOGRAPHIC

Mother’s Education and Employment (Describes the highest degree or level of school completed at the time of delivery) □ 8th grade or less □ Some college credit but no degree □ Master’s degree (e.g. MA, MS, MEng, Med, MSW, MBA) □ 9th – 12th grade, no diploma □ Associate degree (e.g. AA, AS) □ Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD) □ High school graduate or GED completed □ Bachelor’s degree (e.g. BA, AB, DS) □ Not Stated / Unknown Mother’s Business/Industry ______Mother’s Occupation ______Was Mother Employed During The Past Year? □ Yes □ No Mother’s Employer Name ______Mother’s Employer Street Address ______Mother’s Employer City ______Mother’s Employer County ______Mother’s Employer State/Country ______Mother’s Employer Zip ______

Hispanic Origin? (Check the box that best describes whether the mother is Spanish/Hispanic/Latino. Check the “No” box if mother is not Spanish/Hispanic/Latino.) □ No, not Spanish/Hispanic/Lano □ Yes, Puerto Rican □ Yes, Mexican, Mexican American, Chicano □ Yes, Cuban □ Refuse □ Yes, other Spanish/Hispanic/Lano (Specify) ______

Mother’s race? Check one or more races to indicate what the mother considers herself to be. □ White □ Japanese □ Samoan □ Black or African American □ Korean □ American Indian or Alaska Nave (Tribe) ______□ Asian Indian □ Vietnamese □ Other Asian (specify) ______□ Chinese □ Nave Hawaiian □ Other Paciﬁc Islander (specify) ______□ Filipino □ Guamanian or Chamorro □ Other (specify) ______□ Refuse

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SECTION III – SPOUSE’S DEMOGRAPHIC INFORMATION Is Spouse’s Information Provided? □ Yes □ No, Spouse’s Information will NOT be provided. If information is not provided / completed then Spouse will NOT be listed on the Birth Certificate. Are Father/Spouse and Mother married? □ Yes □ No If No, should Father/Spouse be listed on the Birth Certificate? □ Yes □ No Spouse’s Name First ______Middle______Last ______Spouse’s SSN ______Spouse’s Birth Place ______(State / Country) Date of Birth______Age ______(MM/DD/YYYY) ● Is Spouse’s residence same as mother’s residence? □ Yes □ No [If you answered No, complete below] Spouse’s Residence Street Address ______Spouse’s Residence City/Town ______Spouse’s Residence Zip ______Spouse’s Residence County ______Spouse’s Residence Municipality ______Spouse’s Residence State/Country ______Spouse’s Residential Phone Number ______● Is Spouse’s Mailing Address the same as residence? □ Yes □ No [If you answered No, complete below] Spouse’s Mailing Address ______

Spouse’s Education and Employment (Describes the highest degree or level of school completed at the time of delivery) □ 8th grade or less □ Some college credit but no degree □ Master’s degree (e.g. MA, MS, MEng, Med, MSW, MBA) □ 9th – 12th grade, no diploma □ Associate degree (e.g. AA, AS) □ Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, DDS, DVM, LLB, JD) □ High school graduate or GED completed □ Bachelor’s degree (e.g. BA, AB, DS) □ Not Stated / Unknown Spouse’s Business/Industry ______Spouse’s Occupation ______Was Spouse Employed During The Past Year? □ Yes □ No Spouse’s Employer Name ______Spouse’s Employer Address ______

Hispanic Origin? (Check the box that best describes whether the spouse is Spanish/Hispanic/Latino. Check the “No” box if spouse is not Spanish/Hispanic/Latino.) □ No, not Spanish/Hispanic/Lano □ Yes, Puerto Rican □ Yes, Mexican, Mexican American, Chicano □ Yes, Cuban □ Refuse □ Yes, other Spanish/Hispanic/Lano (Specify) ______

Spouse’s race? (Check one or more races to indicate what the spouse considers himself/herself to be.) □ White □ Japanese □ Samoan □ Black or African American □ Korean □ American Indian or Alaska Nave (Tribe) ______□ Asian Indian □ Vietnamese □ Other Asian (specify) ______□ Chinese □ Nave Hawaiian □ Other Paciﬁc Islander (specify) ______□ Filipino □ Guamanian or Chamorro □ Other (specify) ______□ Refuse

SECTION IV – BABY’S INFORMATION Would you like to request a Social Security number for your child? □ Yes □ No What will be the baby’s last name? ______Baby’s First Name (if decided): ______Pediatrician you will be using (if decided): Name of Practice: ______Dr. ______Phone Number: ______Email or Fax: ______

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PATIENT RIGHTS AND RESPONSIBILITIES In order to ensure effective patient care, Our Birthing Center has adopted a Patient Rights Policy. This policy, in full, is posted at Our Birthing Center and is available to our patients and family upon request. Below you will find a summary of Patient Rights as well as responsibilities.

RIGHTS:

1. You are entitled to be treated with courtesy, consideration, respect, and recognition of your dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy. Your privacy shall also be respected when facility personnel are discussing the patient. 2. You are entitled to personal, respectful and safe care without discrimination, harassment or abuse. 3. You are entitled to exercise your civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at any religious services shall be imposed upon any patient. 4. You are entitled to know the names and functions of the people involved in your care. 5. It is the facility’s responsibility to explain your care in language which you can understand. 6. No diagnostic or therapeutic procedure will be performed on you without your expressed verbal or written consent. 7. You have the right to refuse medication and treatment after possible consequences of your decision have been explained to you, understanding that refusing may hinder your ability to deliver at OBC. 8. You have the right to be fully informed about your treatment, procedures and the expected outcome before it is performed. 9. To receive care in a safe setting. 10. No research or experimental procedures will ever be used on you without your full consent. 11. You are entitled to know if other healthcare or educational institutions will be involved in your care and you have the right to refuse such involvement. 12. You are entitled to be informed of Our Birthing Center’s policies regarding life‐saving methods and arranging for that care. 13. If further care is required you may be transferred to Morristown Medical Center. 14. Your medical records are only for the purpose of your care. No information in them will be released or shared without your permission, except as directly needed for your care or as required by law. 15. Our Birthing Center will, upon request, review and provide an explanation of your bill, even though it may be covered by insurance. 16. You are entitled to present any grievances or complaints to the Clinical Director, Donna Roosa, CNM at 973‐ 228‐3550. Or a member of the Governing Authority, Marc Stern at 732‐370‐5627 or Ari Saltz at 646‐340‐8726. RESPONSIBILITIES: You are expected to: 1. Provide accurate information about your medical history. 2. Cooperate with the personnel at Our Birthing Center. 3. Ask questions if you do not understand directions or procedure. 4. Be considerate of other patients. 5. Provide information necessary for processing your insurance coverage. 6. Be ultimately responsible for any agreed payments as per the Financial Agreement. 7. Be respectful of Our Birthing Center facility. 8. Help the midwives, nurses and medical personnel in their effort to give you quality care by following their instructions and medical orders.

I, ______certify that I understand my Rights and Responsibilities as a patient of Our Birthing Center.

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TERMS OF ENROLLMENT GENERAL STATEMENT Our Birthing Center is a free‐standing birth center that offers what is considered an alternative out‐ of‐hospital approach to normal childbearing. It may appeal to and be desired by some people and not others. For this reason, we think it is important that you be fully informed about our services. We require that you participate in the orientation procedures prepared by our professional staff which includes: 1) your personal inspection of OBC facilities, 2) a childbirth preparation class orienting you with our procedures, methods and services, as well as our mutual expectations and 3) frank discussions of how hospital delivery and delivery at OBC differ. We have taken every reasonable precaution to insure your safety, comfort and satisfaction. The birthing center will assure that nurses are available on a 24‐hour a day, 7‐days‐a‐week basis. Our Birthing Center has on hand all the equipment and medication that we think is necessary for normal childbearing in a homelike setting and is in compliance with the standards set by the New Jersey Department of Health. We do not have an electronic fetal monitor, an operating room or an intensive care unit for mother or baby, nor do we have the highly specialized services and equipment which such units contain. Blood and blood products and epidural anesthesia are not available. All are available at Morristown Medical Center (MMC) which is OBC’s back‐up facility and is less than 2 miles away. Nevertheless, some physicians and professional organizations have opposed birthing centers because they believe that there are certain inherent risks to mothers and babies in not being delivered in a hospital. In the case of an emergency, you will be transferred to MMC according to established procedures. In both an emergency or non‐emergency transfer situation one of OBC’s staff members will accompany you to the hospital. If your transfer is non‐emergent and the care needed continues to be within the scope of midwifery practice, your midwife will continue management of your care at the hospital, provided that she is credentialed and has privileges at MMC. If your transfer is emergent, management of your care will be provided by our consulting physicians, One to One Female Care and/or MMC OB/GYN, depending upon the situation. All hospital expenses incurred shall be your obligation and are not included in your financial arrangements with OBC. Your midwife is responsible to provide you with all normal pre‐natal care and postpartum care, including a 24‐48 hour postpartum visit, a 1‐week visit and a 6 week visit. It is your obligation to select and arrange for pediatric care for your baby. This includes completing Pulse Oximetry Screening and Metabolic Screening at your 24‐48 hour postpartum follow up visit; selecting a pediatrician; and arranging for the newborn hearing screening testing. It is wise for you to make these arrangements well before your due date and discuss with your nurse‐midwife. Because of the center's philosophy of trust and honesty, all decisions concerning your health and the health of your baby will be discussed fully with you whenever possible. Do not hesitate at any time to ask any questions you have about our birth center and its functions as well as anything that concerns you, your baby, or your family. Enrollment shall be at our exclusive discretion. Applicants will be notified only after all registrations forms have been submitted and reviewed. We, the undersigned, have read and understood the above statement and have had the opportunity to ask questions. It is entirely acceptable.

______Signature of Mother Date Signature of Father/Spouse/Partner Date

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CONSENT FORM

I, ______hereby request enrollment in Our Birthing Center with the following understandings:

1. Physical Examination: I engage and authorize any member of the midwifery or nursing staff to perform according to the expertise of each discipline, physical examinations on my person to confirm general health and pregnancy status, obtain the usual specimens and perform the usual diagnostic procedures including but not limited to the following: a) drawing blood for Rh factor, serology and other tests, b) pregnancy tests, c) urinalysis, d) blood pressure, e) internal examination ‐ vaginal with or without instruments f) obtaining rectal, vaginal or cervical specimens, including a Pap Smear.

2. Authority to Treat: I engage and authorize any OBC healthcare provider to treat, administer and provide as necessary to me and my baby the following: a) healthcare including prenatal education and instruction b) physical examinations c) obtaining of blood or other specimens or laboratory tests d) oral medications e) intra‐muscular, subcutaneous and intravenous injections and local anesthesia f) intravenous infusions g) delivery of my baby h) episiotomy and repair i) postpartum care j) in‐house newborn care k) follow‐up visits by a staff nurse or CNM l) such other procedures related to childbearing as may be deemed necessary. I grant to the members of the medical team staff full authority to administer and perform all and singular, any drugs, treatments, tests, diagnostic procedures, examinations and ministrations to or upon me and my baby.

3. Informed Consent: While the course of childbearing is a normal human function, it has been explained to me and I understand that in any particular case, medical problems may arise unpredictably and suddenly which may be a hazard of childbearing or of being born or may be aggravated by the stress of childbearing or being born. There are possibilities of excessive blood loss, infection, convulsions, coma, allergic reaction, and respiratory distress. The following are some other medical problems affecting the mother that could occur: placental abruption, rupture of an undiagnosed aneurysm, amniotic embolism, uterine rupture, cardiac arrest, anaphylactic shock, and death. Medical problems affecting the fetus and newborn that could occur are: umbilical cord prolapse and related problems, congenital anomalies, fetal distress, malpresentation, immaturity and post maturity, birth injuries, stillbirth, shoulder dystocia and amnionitis. I understand that certain conditions affecting the newborn, such as the effects of jaundice, blood in‐ compatibility, precipitate labor and respiratory distress syndrome, some congenital anomalies, allergies, infections, and brain damage with or without mental retardation are difficult to recognize or are unrecognizable within 4 to 12 hours of birth by which time families will usually have been discharged. I have been informed with regard to all of the foregoing and advised that I may have more detailed and complete explanations of each condition described and/or other even more remote risks, consequences and conditions. I am aware that advanced practice nursing and midwifery are not exact sciences, and I acknowledge that no guarantees or assurances have been made to me concerning the results of the treatments, examinations and procedures to be performed. I realize that it is the routine practice at OBC that each birth is attended by at least one obstetrical nurse and at least one certified nurse midwife and that the presence of specific members of the staff cannot be guaranteed. I also understand that OBC is a site for the education of students of various healthcare programs (i.e., student nurse

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4. Hydrotherapy: Our Birthing Center has birthing suites equipped with soaking tubs. Additionally, each room has its own private shower. Clients are permitted and encouraged to labor and deliver in the showers and tubs should they so desire as long as the following conditions are met. ‐ The midwife in charge of your care agrees to your use of hydrotherapy. This is subject to the discretion of the CNM managing your care. ‐ No current untreated vaginal, urinary, or skin infections. ‐ Maternal vital signs that are within normal limits. ‐ Reassuring fetal heart rate prior to immersion in hydrotherapy. ‐ Presence of or report of meconium stained amniotic fluid, or vaginal bleeding that is more than a bloody show will render the patient ineligible for hydrotherapy delivery.

5. Patient History and Right to Withdraw: In view of all of the above, I understand that in the selection and treatment of mothers at OBC, you will rely on my medical history and the information about myself which I and my Midwife provide. I affirm that such information is and will be correct and accurate to the best of my knowledge. In addition, I agree to follow all the rules, regulations and policies of Our Birthing Center and I understand that I may voluntarily withdraw from enrollment at any time I wish prior to admitting.

6. Use of Medical Records: I authorize Our Birthing Center and such parties authorized by them to have full access to all my records for statistical studies and other research purposes. The only reservation is that my personal privacy be protected from the general public.

7. Disposition of Placenta: Please initial one of the following: ____ A. I hereby authorize Our Birthing Center to properly dispose of my Placenta. (Placenta will NOT be given over for research purposes.)

____ B. I will be fully responsible for making other disposition arrangements. Failure to remove placenta at time of discharge will constitute approval of disposition under A.

8. Photography: Often, our staff has the opportunity to capture unique photos from your birth. Please be advised that NO photographs will be publicly published or shared without obtaining your permission for the specific photo. I grant Our Birthing Center, its representatives and employees the right to take photographs of me and/or my birth and/or my newborn. □ Yes □ No

9. Affirmation: I have visited Our Birthing Center for a tour and have taken or signed up to take childbirth education classes.

The undersigned understand the operation of Our Birthing Center and its limitations and have had full opportunity to ask any questions.

______Signature of Mother Date Signature of Father/Spouse/Partner Date

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TRANSFERS I understand that certain clinical indicators may necessitate transfer to Morristown Medical Center (MMC) for a more comprehensive level of care. The decision regarding the need for transfer will be made by your midwife. Our Birthing Center has Obstetrical and Pediatric consultants available at all times for consultation in the event of complications requiring further medical care and/or hospitalization. Typically, the midwife will consult with said physicians prior to transfer. Transfers could occur prior to being admitted, during labor, postpartum or for newborn care. If your midwife is not credentialed at MMC she will only be able to accompany you for support but not for clinical care.

The following conditions discovered during labor could cause a transfer from the birthing center to the hospital. Breeched position; Cord prolapsed; Fetal heart rate abnormalities; Particulate meconium in amniotic fluid; Placental Abruption; certain instances of prolonged labor; Uterine Rupture; maternal exhaustion; unstable vital signs; inability to urinate.

The following conditions discovered postpartum could necessitate a transfer from the birthing center to the hospital. Soft tissue problems; severe blood loss; Postpartum hemorrhage failing to respond to appropriate management; Maternal seizures; Any condition requiring more than 12 hours of continuous postpartum observation.

The following conditions discovered with the newborn could necessitate an infant transfer from the birthing center to the hospital. Low Apgar score; Congenital anomaly requiring immediate acute care; Persistent hypothermia; Immediate jaundice; Severe or worsening respiratory distress; Difficult resuscitation; Exaggerated tremors or any seizure activity; Any condition requiring more than 12 hours of continuous post‐delivery observation.

In case of emergency, I authorize any member of the midwifery staff to take appropriate measure, and when specialized equipment or hospitalization is believed required, to transfer me or my baby to Morristown Medical Center (MMC). All of the above is to be performed as deemed necessary or advisable by any member of the midwifery staff in the exercise of his or her professional judgment. In case of a needlestick or sharps injury, I authorize any member of the midwifery staff to take appropriate measures and to transfer me or my baby to Morristown Medical Center (MMC) if necessary or to test for bloodborne pathogens.

______Signature of Mother Date Signature of Father/Spouse/Partner Date

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PATIENT CERTIFICATION I, ______hereby acknowledge, warrants and agrees that:

 I understand that delivery at Our Birth Center is only appropriate for women who are considered low risk as per our established Policies and Procedures; to be evaluated by your care provider.  I understand that even after meeting the low risk criteria I can still be denied admission to the birthing center due to changing circumstances. For example, if it is found that the baby is in a breech position; Premature labor‐ before 37 weeks; Post‐term labor‐ past 42 weeks.  I understand that certain clinical indicators may necessitate transfer to Morristown Medical Center for a more comprehensive level of care. The decision regarding the need for transfer will be made by your midwife. Transfers could occur prior to being admitted, during labor, postpartum or for newborn care. If your midwife is not credentialed at Morristown Medical Center she will only be able to accompany you for support but not for clinical care.  I understand that I may complete an Advanced Directive and it will become part of my medical record. For more information and samples please see www.state.nj.us/health/advancedirective/ad/  I will provide the information necessary for processing my insurance coverage. In the event that my insurance will change from the original Verification of Benefits done, it is my responsibility to inform OBC of the insurance change and to have a new Verification of Benefits done. If I do not inform OBC of an insurance change or a lack of coverage, I understand that I am ultimately responsible for any portion of the facility fee which is not covered by my new insurance.  I acknowledge that the insurance coverage for my newborn will be the same insurance plan that I am currently active with. And I understand that it is my responsibility to add my newborn to my insurance policy immediately after birth. In the event this is not done I will be responsible for the newborn care portion of the fee.  Every effort will be made to allow me to birth in the suite of my choice. However, I understand that birthing suites are distributed on a first come first served basis and I may not end up in the suite I chose.  I understand that even after registering and meeting all criteria it is possible that when it is time for me to deliver it is possible that all three birthing suites can be occupied and I will be denied admittance to the birthing center.  I certify that I have read and understand the entire registration packet. I have had the opportunity to ask questions of my midwife and/or Our Birthing Center, LLC if anything is unclear.

______Signature of Mother Date Signature of Father/Spouse/Partner Date

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FACILITY OUT-OF-NETWORK DISCLOSURE As required by the NJ Department of Health

Patient Name: ______

Patient’s Health Benefits Plan: ______

● Our Birthing Center is out‐of‐network for the health benefits plan named above.

● The total amount you owe may be more than the copayment, deducble, and/or coinsurance amount required by your health benefits plan.

● You may be charged the diﬀerence between what your health beneﬁts plan pays Our birthing Center and what is Our Birthing Center‘s charge for the services provided.

● You should contact the health care professional ordering the services to be provided in Our Birthing Center to determine if he or she is in‐network or out‐of‐network for your health benefits plan.

● You should contact your health beneﬁts plan for informaon regarding your copayment, deducble, and/or coinsurance amount. Contact information is typically found on the card provided to you by your health benefits plan.

● In some cases, health care professionals other than the one ordering the service may provide and bill for care in this facility. You can expect for services to be provided by Avalon Midwives, Midwives of New Jersey, The Childbirth & Women’s Wellness Center and Bio‐Reference (blood work). You can access information regarding the health benefits plans that these health care professionals participate in on their respective websites, www.AvalonMidwives.com, www.MidwivesofNJ.com, www.ChildbirthCenter.net and www.BioReference.com. If you do not have internet access, a copy of this information will be provided to you upon request by Our Birthing Center.

I agree that I have read and understand this form and have been provided a copy of it.

______Patient’s Signature Date

Completed forms along with a copy of photo ID should be emailed to [email protected]