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


Doula Reimbursement Forms

Easy Steps to a Safer Pregnancy - View e-book or Download PDF - FREE!
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.

Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.

To our clients,

This receipt is for your medical records to indicate that you have paid for our doula services. A few insurance companies reimburse expectant parents for all or part of doula services or if you have a health care reimbursement account, this may qualify for reimbursement as a medical expense. We suggest that you complete this form and mail a copy of it with your own insurance carrier's claim form to request this reimbursement. To increase your chances of reimbursement, you should also include: a prescription from your physician/midwife for our services (if possible) and a letter stating the research findings associated with doula care and why you chose to hire a doula.

Please detach here before mailing

                                    Our business name
My name, credentials, address/phone                          My partners
Then I made a box with room for client's name, address, ss#, phones, subscriber and ID #, group #, a place to list other coverage. I made a box for the ICD-9 Diagnosis Code of V22.1 of Iup. Intra-uterine Preg. Also places for EDC, referring physician, a release. Then another box with the codes for private class or doula service, my fee, amount paid and balance due. Last box with my signature and date.

If I knew how to attach something from my word processing files into aol e-mail I would be happy to do this as the form looks pretty good (if I may say so myself!)

Anyone is welcome to use my top paragraph and this format, after all, I patterned it after others. Also, if anyone has any ideas/suggestions for improvement, let me know. Also, in our prenatal packet, we give them info on advantages of doulas and the K&K study from Mothering the Mother that they can cite to insurance.

This Web page is referenced from another page containing related information about Money and Paperwork


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