MATERNITY CARE AGREEMENT: MEDICAID
Welcome to Family to Family! It is an honor to serve you and your family. We hope that you have read and
understand the details of our services and payment options. Please select the payment option that applies to you. Please
bring this agreement along with a copy of your insurance card to your first appointment, at which time one of our staff
will review this agreement with you in person and answer any questions. Also, please arrange with our office to have
your previous prenatal/birth medical records sent to Family to Family, prior to your first visit.
Pregnancy Medicaid will cover all of your prenatal, hospital, postpartum fees. There is no out of pocket expense for
Medicaid covered services. Charges are set by Medicaid and payment is made directly to Family to Family.
Please note that the legal name of our business is Helper, PA. This name may show up on your caller ID or other
documents you may receive from your insurance company.
Pregnancy Medicaid includes the following:











Prenatal care, birth and postpartum care for a full two months after baby is born; this includes prolonged care
during birth if needed. Typically, women begin prenatal care at eight-twelve weeks and sometimes continue
prenatal care up to 42 weeks gestation. Visits begin monthly and increase in frequency from every two weeks
to weekly as pregnancy continues. We recognize that prenatal care is more than simply measuring your belly,
listening to your baby, checking blood pressure. We believe your investment in your prenatal care includes a
trusting relationship with your doctor. We value getting to know you and your family, listening to you,
discussing various topics related to this time in your life, exploring the various emotional changes that may be
occurring, and helping you with birth planning and decision making. We welcome the father of the baby and
siblings to participate in prenatal care as well.
Your appointments with our doctors range from 30 to 90 minutes and occur in the office or at home. The
initial visit is typically 90 minutes. Most follow up visits are 30 minutes except at 28 and 36 weeks which are
both 45 minutes visits. We schedule a one hour birth team meeting at 37 weeks.
Additional office visits to treat medical conditions which may complicate pregnancy such as UTIs, diabetes
or hypertension are covered.
Attendance and care during your labor and birth from Dr. Lichtig or the MAHEC Family Practice Resident.
Our doctors take a hands-on approach during labor; though we still encourage you to consider hiring a
doula.
After-birth care in the hospital for 24-48 hours as needed. Includes daily visits from the physician to review
breastfeeding, help with adjustments to parenthood, and other needs as they arise; as well as oversight of
hospital care.
Post-partum care up to two months: We see you and your baby (if you choose us to also be your baby’s
pediatrician) within the first two weeks. Depending upon driving distance, your preference and availability
in our schedule, we come to your home for the initial postpartum visit. We then see you for a 30-45 minute
postpartum office visit at six weeks: this includes pap if needed and pelvic exam, discussion of birth control
needs, any breastfeeding or postpartum depression issues. If you need more involved postpartum care or
breastfeeding support, we are happy to schedule additional visits. If you choose to have an IUD or
diaphragm post-partum this is done in a separate visit from your routine six week visit. After your final six
week visit, we only accept Medicaid until the end of the month. We are happy to continue to see you for
ongoing primary care or consultations, however, you need to read and sign our adult care agreement and
understand that payment in full is expected at the time of service.
In house labs that may be needed such as urinalysis or hemoglobin.
Physician interpretation of tests such as non-stress tests or explanation of ultrasounds and other labs.
Access to our lending library and in house DVDs (donations are generously accepted)
Care coordination with other providers as needed.
Specimen handling fees for sending out various labs.






24 hour phone access to Dr. Lichtig’s cell phone or the MAHEC Family Practice REsident to address your
questions, concerns, or urgent needs up until your six week post-partum check up.
Childbirth classes if the childbirth educator accepts Medicaid. Additional out of pocket fees may be required
for classes beyond what Medicaid covers.
Family planning services
Care during and after pregnancy loss
Pregnancy Medical Home: care coordination from a case manager who works at our office and is specialized
in ensuring people who are at high risk or have additional needs receive support.
All hospital fees associated with pregnancy or birth.
Pregnancy Medicaid does NOT include the following: You will be responsible for full payment to Family to Family
for all non-covered items at the time of service.





Supplements, herbs, vitamins
Books
Classes not covered by Medicaid
Non-pregnancy related medical visits
Circumcision, Silicone diaphragms
To qualify for Pregnancy Medicaid, the monthly family income cannot exceed 185% of the federal poverty level.
Your monthly countable income cannot be more than the amounts listed below.
Monthly Family Income Limits: Medicaid for
Pregnant Women (Effective April 2009)
Family Size
Monthly Income Limit
2
$2,247
3
$2,823
4
$3,400
(The unborn child is always counted in the family size.)
Do you think you might be eligible? It is worth applying to see! You can apply at the Buncombe County Department of
Social Services. Call 828-250-5500 or visit the Family Medicaid office located on the first floor of the Department of
Social Services at 40 Coxe Ave. Hours of operation are 8:00 AM to 5:00 PM. Once you are approved for Pregnancy
Medicaid, they mail you an insurance card and your previous prenatal appointment fees are covered retroactively
provided you apply within two months of your first visit.
Signed Agreement
I have read the document on Maternity Care Services as well as this Maternity Care Agreement and have
reviewed it in person with a Family to Family staff member.
GENERAL AGREEMENT
 I have asked Family to Family to provide me with a Pregnancy Verification letter so that I may apply for
Medicaid and have my appointments covered retroactively to the beginning of my pregnancy.
 I have reviewed the online list telling me what items I need to bring to my application appointment. It is
located at: http://www.dhhs.state.nc.us/dma/medicaid/apply.htm.
 If I do not apply and receive Medicaid in a timely way to cover my cost of care, I agree to pay Family to
Family’s in full by check, cash or credit card their standard out of pocket fees for all visits and lab services that
I receive.
 I have been approved for Pregnancy Medicaid?: Yes or No or Pending
 If I already have some form of Medicaid, I have contacted my case worker and have requested maternity
benefits. Yes or No
 If I already have Pregnancy Medicaid, but am listed with another provider, I have contacted my case worker
and changed my provider to Family to Family. Yes or No
 I agree to inform Family to Family of any changes in my legal name, mailing address, phone number or
insurance status within one month of changes.
 I agree to pay for all non-covered items at the time of service in full.
 I understand that after my six week post partum visit that I can continue to be a patient at Family to Family
under the adult services agreement. I understand that they will no longer take regular Medicaid and that I will
pay in full at the time of service according to their fee schedule.
 I have received the on call schedule; I know how to get in touch with my doctors or the MAHEC Family
physician in the event that my doctor is unavailable.
 I fully understand and agree to all policies and procedures concerning services offered, how to use the system
as well as the financial aspects of the practice including my responsibility in getting my EOBs to Family to
Family in a timely way so that Family to Family can get paid. In the event that I fail to provide Family to Family
with the necessary paper work so they can properly file with Medicaid, I will be responsible for and will pay my
bill in full. I will bring in all EOBS (explanation of benefits) from my insurance company within one month of
receiving them.
 I agree to pay my bill in full at the time of service for fees that I am responsible for as outlined in this
agreement. If for some reason, I do not pay at the time of service, I agree to pay in full within 30 days of being
called or receiving a written statement of my bill.
 I agree to keep FTF aware of changes in my phone number, mailing address and email address so they can
effectively contact me.
 I understand that the fees set in this maternity agreement do NOT include fees for non pregnancy related
medical visits, herbs, supplements or books that may be recommended by the doctor.
 In the event that my insurance company sends a check directly to me for physician services that I haven’t yet
paid for, I will deposit the check and immediately pay Family to Family the same amount rendered by my
insurance company in a personal check, cash or credit card to Family to Family
 I understand that if I transfer care, there is a $25 processing fee for records that is not covered by Medicaid,
thus I agree to pay this fee to Family to Family directly.
 I have requested that any relevant previous medical records are sent to Family to Family before my first
appointment. ____ YES ____ NO ____ N/A
 I understand that my personal demographic, financial and health care information is kept private, confidential
and secure at Family to Family and will only be used for the appropriate purposes of offering me or my family
member care, making referrals or securing insurance reimbursement.
 I give my permission for Family to Family to share my medical information with referring providers and my
insurance company for the purposes of my care or reimbursement.
 I give my permission for Family to Family to share my medical information or discuss my care with the
following friends or family members:
1. ___________________________________, 2. __________________________________
3. ___________________________________, 4. __________________________________
 I authorize Family to Family to release all medical and/or insurance claim information necessary to secure insurance
payments. I authorize the processing of commercial medical insurance and/or Medicaid.
 My signature authorizes payment directly to Family to Family when applicable.
 I authorize Family to Family to render treatment to me and provide information to me personally regarding my care and
agree to receive alternative diagnostic and treatment approaches that are considered safe but non-standard.
 I understand that this agreement will end after my 6 week post partum visit at which time I can continue receiving care
at FTF under the adult services agreement where payment in full is expected at the time of service.
 Sharing your birth story: In sharing, we learn. Our time together can be helpful in teaching and inspiring others. No
one tells the story of our care better than you! If we receive your permission, we’d like to be able to share the story and
possibly photographs of your pregnancy and birth with our colleagues, patients, residents and students for teaching
purposes only. No identifying information or names will be shared.
Please check the appropriate boxes to provide such permission:

Birth Plans:
yes
no
Photographs:
yes
no
Birth Stories:
yes
no
PLEASE CHOOSE AN OPTION
OPTION 1: PRIMARY PREGNANCY MEDICAID AGREEMENT
 I have confirmed that I DO NOT have any other form of insurance: Yes or No
 I understand that I am responsible for full payment to Family to Family for all non-covered items at the time of
service.
OPTION 2: PRIMARY PREGNANCY MEDICAID WITH COMMERCIAL INSURANCE THAT
DOESN’T INCLUDE MATERNITY BENEFITS
 I also have another form of insurance but DO NOT have maternity benefits: Yes or No
 I understand that even though I don’t have maternity benefits under my other insurance, Family to Family
must first bill my primary insurance before billing Medicaid. My primary insurance will send Family to Family,
or me directly, an explanation of benefits showing denial for each of the visits, birth, and classes.
 I authorize my signature to be on file with my provider(s) at Family to Family, authorizing my EOBs (aka
Explanation of Benefits or EOB) to go directly to Family to Family.
 If for any reason my EOBs do not go directly to Family to Family, I agree to bring in copies of any insurance
forms, EOBs, I receive from my insurance company to Family to Family within one month of receiving
them. Note that the insurance company EOB will be under the following providers: Dr. Lichtig, Family to
Family or HELP ER, PA which is the legal name for Family to Family. Without this, Family to Family is unable
to bill Medicaid.
 I have provided Family to Family with a copy of my other insurance card to assist them in billing my other
insurance company first.
 I agree to call my insurance for copies of these denials if requested by Family to Family within one month of
request.
 I understand that I can request via telephone for my insurance company to fax Family to Family my eobs
directly. I also understand that I can log into my insurance account online and email them to Family to Family
directly from the copies that are available to me online. Fax: 828-251-2700. Email: info@familytofamily.org.
I understand that it is my responsibility to ensure that Family to Family has what they need to bill Medicaid and
my failure to provide them with the necessary materials may result in Medicaid not covering charges to my
account, in which case I will be financially responsible for all fees for services incurred and agree to pay in full
within one month of receiving a bill.
 I understand that I am responsible for full payment to Family to Family for all non-covered items at the time of
service.
Your signature indicates that you have read in full and agree to the terms stated in this agreement.
Signature of Patient
Print Name of Patient
Date
____________________________________________________________________________________
Signature of Mother
Print Name of Mother
Date
____________________________________________________________________________________
Signature of Father/Partner (if applicable)
Print Name of Father/Partner
Date
____________________________________________________________________________________
Signature of FTF Employee
Print Name FTF Employee
Date
____________________________________________________________________________________
Personal Information
Legal Name of Patient _______________________________________ Nickname ___________________
Name of all parents/guardian (if applicable)
___________________________________________________
Patients Date of Birth ___________________________________________________________________
Patient/Parent/guardian email: ____________________________________________________________
Is it OK to send confidential medical information to you via non-encrypted email? ___YES ____ NO
Is it OK to communicate with you via non-encrypted email? ___YES ____ NO
Phone_____________________________ (Preferred contact number)
Is it OK to leave medical information/appointment reminders on this number? ____ YES ____ NO
Phone_____________________________ (secondary)
Is it OK to leave medical information/appointment reminders on this number? ____ YES ____ NO
Phone_____________________________ (other, specify)
Is it OK to leave medical information/appointment reminders on this number? ____ YES ____ NO
Address
Emergency Contact Name & Relationship to you:
Emergency Contact Phone:
City
State
Zip
Credit Card information is kept in a secure location. Family to Family reserves the right to charge your card for
any services not paid for at the time of service. This is to ensure Family to Family gets paid in a timely way for
costs you might incur that are not covered. We require this information for our security purposes.
Type of Card_________________________________________________
Card # and 3 or 4 digit code _____________________________________
Name on the card _____________________________________________
Expiration Date _______________________________________________
Primary Insurance
Insurance company:
Insurance company address:
Insurance company phone #
Subscriber or Medicaid #
Group #
Name of Policy Holder:
Relationship to patient:
Policyholder’s Date of Birth:
SS# of Policy Holder:
Effective Dates: Coverage begins
Coverage ends
Secondary or Change of Insurance
Insurance company:
Insurance company address:
Insurance company phone #
Subscriber or Medicaid #
Group #
Name of Policy Holder:
Relationship to patient:
Policyholder’s Date of Birth:
SS# of Policy Holder:
Effective Dates: Coverage begins
Coverage ends