COLUMBUS COUNTY HEALTH DEPARTMENT
MATERNITY CLINIC
MEMORANDUM OF UNDERSTANDING FOR PARTICIPATING IN THE MATERNITY CLINIC
You are about to take part in the Maternity Clinic which is a service to provide prenatal care. There is certain
responsibilities the clinic and you must agree upon.
The CLINIC will provide you with the following services.
1. Physical examinations
2. Interpretation of medical and family history
3. Individual counseling by nurse, social worker, nutritionist, health educator, pregnancy care managers
or others
4. Laboratory and diagnostic studies
5. Education about pregnancy, labor and delivery, early child care, and family planning
6. Vitamins, iron and other medication if needed (prescription medication)
7. Regular scheduled checkups in clinic
8. Pregnancy Care Manager home visit when and if indicated
9. If uninsured, Medicaid Presumptive Eligibility Form will be completed on your first visit. This coverage
will expire by the last day of the following month (Ex. 1st visit 10/10/15 expires 11/30/15) or as
determined by DSS. On your 32 week visit you will be reminded to go to DSS immediately and sign up
for Medicaid which covers the hospital, labor, and deliver costs.
10. Columbus County Health Department will NOT be responsible for emergency room visits, or hospital labor
and delivery cost.
11. If you are denied Medicaid


Your financial eligibility will be determined on a sliding fee scale and you will be expected to pay accordingly.
If you are unable to pay the total amount of the bill, you will be asked to sign a payment agreement.
You are expected to take part in your care and are required to do the following
1.
2.
3.
4.
Keep your appointments and be on time
Call the clinic if you cannot keep and appointment
Let the clinic know if you move and do not wish to continue receiving the services
Patient will consult with the Pregnancy Care Managers for appointment scheduling, counseling,
assistance with community services, and take part in ongoing prenatal education provided by the care
managers.
5. IMMEDIATLEY report to the clinic (or if after hours the Columbus Regional Healthcare Emergency
Department) if you have the following danger signals.
A.
B.
C.
D.
E.
F.
Severe vomiting
Frequent or severe headaches
Continuous abdominal (stomach) pain
Bleeding from the vagina
Dizziness, blurring of vision or bright flashing lights
Burning, pain or bleeding when passing urine
G. Chills or fever
H. Loss of fluid from vagina (not vaginal discharge) but a gush of watery (type fluid or continuous
leaking of fluid.
I. Swelling of hands, feet or face that persists.
J. A significant decrease or no fetal movement; a significant increases of movements
6. Take no medications, including prescription, over-the-counter, or other drugs unless advised by the
staff of the Maternity Clinic
7. Go to the hospital if:
A. If the baby is due and you are having contractions (pains) and this is your first baby—wait until
your contractions are regular and five (5) to ten (10) minutes apart or as directed by clinic. If
this is your second or more baby –wait until the contractions are regular and are 15 minutes
apart or as directed by clinic. (Allow for road condition, distance to the hospital, history of short
labor, and irregular contractions which are increasing in intensity)
B. If baby is not due yet and you are having contractions (notify your medical provider )
C. Your water breaks or leaks
D. You have bright red bleeding
8. If you think you are in labor, limit your food intake to a light diet and drink fluids.
9. You are expected to make arrangements for your hospital stay as directed by the clinic or directed by
the clinic or hospital staff.
10. You are asked to write down your questions and bring them with you for discussion during routine
prenatal visits.
11. For important questions that cannot wait until the next visit and reporting danger signals, please call
the Maternity Clinic (phone) 640-6615. Between the hours of 5:00 PM and 8:30 AM, when the Health
Department is closed, call 642-9331 or 642-9334 in labor and delivery for emergency situations.
I have been given oral and written instructions and have been given the opportunity to ask
questions about this memorandum. I have also been given a copy to refer to as needed. I fully
understand the above and consent to participate in the Maternity Clinic and accept the responsibility
of carrying out this agreement. I give my permission for the Columbus County Health Department to
send a copy of my prenatal record to the following physician:
Physician(s): Baldwin Woods Gynecological PA
Hospital: Columbus Regional Healthcare System
Other: __________________________________
_________
Date
Revised 10/20/2015
__________________________________________
Patient Signature
____________________
Witness