Financial Agreement/Insurance, Denali Kid Care and Private Pay
Fees: Our deposit for midwifery services during pregnancy, birth and postpartum is $1500. The
deposit helps prevent you from owing a large amount of money after your insurance has been billed
and is due in full by 36 weeks. The deposit is applied to the deductible and co-insurance amounts.
After the verification of benefits is done, we will outline a payment plan to pay the remainder of the
deposit. If the deposit has not been paid in full by the 36th week, the midwives may not be able to
attend your birth, unless other arrangements have been made in writing.
Each client will be responsible for the fees pertaining to their care. We will gladly bill your
insurance as a courtesy for you however; it is ultimately your responsibility to pay if your insurance
company has not paid. We ask that you pay any costs you are responsible for at the time services
are rendered or in accordance with the payment plan you have negotiated.
Cost of Services
Consultation and Orientation
Childbirth Class
Home birth Tub rental
Home birth supply kit
Lending Library
Pregnancy Testing
Supplements
Supplies (example: baby sling)
Global Birth Fee
Labor and Birth
Facility Fee
Newborn Facility Fee
Newborn Examination
Free
$50
$75
$50
Free
Free
Prices vary
Prices vary
$6500
$3500 + Procedures/Medications
$3500 Includes all supplies
$2000
$275 + Procedures/Medications
Denali Kid Care/Medicaid
For moms with Denali Kid Care/Medicaid (DKC), all costs are reimbursed by DKC or absorbed by
Alaska Family Health & Birth Clinic (AFH&BC) except childbirth class, supplements and supplies.
You are responsible for paying those costs directly. Payment is expected for childbirth class,
supplements and supplies at the time you receive those services or items. Please understand that
AFH & BC has to absorb all costs incurred that are not reimbursed by DKC.
2054 30th Avenue· Fairbanks, AK, 99701 · (907)456-3719·Fax (907)456-1511
Billing Insurance: If you have insurance with maternity benefits, our billing service will bill your
insurance company for these services. By entering into this contract, you authorize our billing
service to release health information to your insurance company for the purpose of processing your
claims. Please note that there is no guarantee your claims will pay, as some insurance plans cover
midwifery services and some do not.
Our billing service may bill your insurance company for the following services related to your care
including, but not limited to:
Initial visit, global fee including delivery, intra-partum care, supplies, IV therapy, newborn
exams & PKU, postpartum home visits, (facility fees for birth center).
We will bill your insurance company for all applicable codes that represent the care we provide to
you at usual and customary rates for those codes. The amount of the deposit has no bearing on the
fees that we bill to the insurance company.
The deposit will be applied to the deductible and co-insurance amounts applied by your insurance
company to our claims. If the insurance company pays us directly, you may be eligible for a partial
refund of the deposit.
If your insurance company reimburses you directly, which is not uncommon, you agree to contact
us immediately. We will determine how much is yours to keep and how much you should send to
us. It is not legal for you to profit on your healthcare; therefore, any amount reimbursed by
insurance that exceeds the deposit must be forwarded to us, along with applicable amounts to
cover your deductible and co-insurance.
Insurance is a contract between you and your insurance company. We will bill your insurance
company as a courtesy to you. In order to properly bill your insurance company we require that you
disclose all insurance information including primary and secondary insurance, as well as, any
change of insurance information. Failure to provide complete insurance information may result in
patient responsibility of the entire bill. Although we may estimate what your insurance company
may pay, it is the insurance company that makes the final determination of your eligibility and
benefits. Deductible and co-pays are due at time of visit.
Self Pay
Payment is due when services are rendered for families who self pay. The birth fee is due by 36
weeks. A 10% discount will be given to office visit charges when paid at time of service. A 10%
discount will be given to the birth fee when paid by 36 weeks gestation. There will not be a price
reduction for the birth fee for those who don’t pay ahead, or for any outstanding balance.
There is a sliding scale available for those who meet the income requirements and are uninsured or
cannot qualify for Denali Kidcare. To qualify for sliding scale we will need proof of income. Sliding
scale fees apply when the account is paid at the time of service. The birth fee is due by 37 weeks.
There will not be a price reduction for the birth fee for those who don’t pay ahead, or for any
outstanding balance.
Other Costs
Physician visits or extraordinary diagnostic tests (such as ultrasound) outside of AFH&BC are your
responsibility and will be paid to the clinic, hospital or physician involved. Also, in the event of a
transport to the hospital, any service rendered by the ambulance or hospital is your responsibility.
2054 30th Avenue· Fairbanks, AK, 99701 · (907)456-3719·Fax (907)456-1511
Outstanding Balance
Communication with billing is encouraged for any problems with payment. We may be able to
negotiate a plan that is suitable for you. We will not turn anyone away for financial reasons, but we
expect you to take responsibility for making arrangements with us. In the event that your account
does become delinquent we will refer your account over to collections.
At 90 days, any outstanding balance becomes subject to collection. If your account is sent to an
outside collection agency, a 40% fee will be added to your balance due.
Transfer of Care before labor
In the event that you transfer to another care provider before labor begins, you will be charged only
for services you have received.
Transfer of Care in labor
If you are delivered at the hospital, we do not receive payment for your birth. We bill for labor
management at the center because more than likely, we will have spent hours at your side, and
simply cannot afford to work for free. This fee varies; depending on how many hours we managed
the labor.
Sometimes there are complications that require you to be transferred to the hospital in the middle
(or end) of labor. We will charge the full facility fee if we spend hours at the birth center, using
supplies and equipment. We regret that a prolonged labor and possible physician/hospital delivery
will increase you costs; however, we cannot stay in business without billing for our time, and
expenses.
We will accompany you to the hospital and give you the support you need and hand your records
over to the doctor. We do not receive any payment from insurance or DKC for our time spent at the
hospital. We will gladly see you for postpartum care after the birth.
Care Not Covered by Insurance: It is understood that you are ultimately responsible for payment
of all charges on your account regardless of how the insurance company responds/reimburses.
Birth Center Facility Charge
$3500.00
The following rules apply to all clients wishing to have their babies at Alaska Family Health & Birth
Clinic:
1. We will gladly bill your insurance for you after the birth; however, it is ultimately your
responsibility to pay if your insurance company has not paid. The transfer agreement is as
follows:
a. If you spend less than one hour in the birth center, and end up transferring to the
hospital do to risk, you will be billed a minimal charge, depending on supplies and
services rendered.
b. If you spend more than one hour in the birth center and end up being transferred to
the hospital, you will be billed at the minimum, 50% of the full facility fee. If you
spend over eight hour at the birth center you will be billed for the full facility fee.
2. We will gladly accept Visa, MasterCard, or Discover for your pre-pay or entire facility fee.
2054 30th Avenue· Fairbanks, AK, 99701 · (907)456-3719·Fax (907)456-1511
Signature Page
Financial Agreement/Insurance, Denali Kid Care and Private Pay
I acknowledge full financial responsibility for services rendered by Alaska Family Health &
Birth Clinic. I understand that I am responsible for prompt payment of any portion of the
charges not covered by insurance, including deductibles and co-insurance. I understand that
a 40% fee will be added to any account balance that is turned over to collections.
Signature____________________________________________________________ Date___________________
Print name _________________________________________________________
Witness______________________________________________________________ Date___________________
Photo/ Website Release
I give Alaska Family Health and Birth Center permission to display photographs and birth
announcements in the birth center, on the web site, Facebook, DVD and literature.
YES
NO
Signature_____________________________________________________________ Date___________________
2054 30th Avenue· Fairbanks, AK, 99701 · (907)456-3719·Fax (907)456-1511