The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Home Birth Financial Agreement

Here is a copy of my financial agreement. Since I cover a wide range in travel, my fee is adjusted to the distance I have to go to account for not only mileage, but also the extra time & difficulties of being further from home that entails.

Financial Agreement for Home Birth Services through A Touch of Life

I understand that the basic fee for home birth midwifery services provided through , is $----. All phone calls from the midwife will be COLLECT. This financial agreement covers the midwifery care of prenatal visits, and responsibilities throughout pregnancy, labor and delivery, as outlined in the ATOL Informed Consent Statement, which was provided for me to read before signing this agreement.

The first $100., which shall serve as a NON-REFUNDABLE retainer, is due with the first prenatal visit. Thereafter I understand that $100. is expected to be paid at each visit. All payments will be applied to the $----- balance; plus the addition of any other vitamins, lab, supplies, or herbs. FAILURE TO PAY IN FULL BY THREE WEEKS BEFORE THE DUE DATE RELEASES THE MIDWIVES FROM RESPONSIBILITY TO BE ON CALL FOR A HOME DELIVERY. PRENATAL RECORDS WILL BE MADE AVAILABLE TO ME TO TAKE TO THE HOSPITAL IN THAT CASE.

If care is discontinued before the 37th gestational week (three weeks before the due date), a refund from what has been paid LESS $100., non-refundable retainer and charges for visits, and supplies to that point will be made according to the following schedule of refund deductions for visits made with the midwife:

        Initial Visit           $----
        Routine Prenatal Visit  $----
        Emergency Office Visits$----
        Weekend Office Visits   $----
        Home Visits     $----
        Doctor's Office Visit   $----
        Educational Preparation$----
        Per Mile Traveled (by midwife and assistant $.30)

Costs not covered by the $---- fee are: vitamins, birth supplies, doctor fees, lab work, medications my doctor may advise me to have, transport by ambulance, or hospital fees.

Dependability with payments is expected since "good intentions" on your part do not pay our bills. The fees for service allow us to not have to work another job that would prohibit us being available to you as a midwife. They also allow us to keep our equipment ready and in good working order, and for the upkeep and gas on vehicles to ensure our presence at your birth.

We realize meeting the expenses will take some planning for most families. However, we can not cause debts on our families to pay for another's baby. WE CANNOT CARRY YOU AS A DEBT, and if meeting the fee is a problem we suggest you obtain a personal loan from other members of your own family, or institutions set up to handle such debts. YOU ARE RESPONSIBLE FOR MEETING YOUR OWN EXPENSES.

We request you accept the above payment schedule of $100. per month, with the entire fee paid before your birth. If you find you have to deviate from this, please consult with us and let us know so that we may prepare for a decrease in our own family budgets.

I UNDERSTAND THE SERVICES OFFERED BY , THE FEES CHARGED FOR THOSE SERVICES, AND SHOW MY ACCEPTANCE OF RESPONSIBILITY AND AGREEMENT TO THESE FINANCIAL EXPECTATIONS. INSUFFICIENT CHECKS WILL ACCRUE A CHARGE OF $35.

I pledge at least $ 100. per month before the birth, and the balance will be paid in full by THREE WEEKS BEFORE my due date.

_________________________  ________     
            Signature Mother                      Date

_________________________  _________

Signature Witness Date