OB Contract
Congratulations, you’re pregnant! Thank you for choosing Millennium Gynecology as your pregnancy care specialist. Providing excellent care for you and your baby requires a team effort, and this agreement should help you understand your financial requirements. We are proud of the outstanding care we provide, at such incredibly affordable rates.
This agreement ensures that Millennium Gynecology will be providing Pre-Natal Services from the date of signature until 6weeks post-partum. I, the patient, agree to the following responsibilities and requirements:
1.I promise to complete payment for all pre-natal services by 34 weeks.
2.I promise to pay for any additional services prior to service or within 24hours of notification.
3.I promise to notify the practice of any change in address or contact information immediately
4.In the event of premature delivery, termination of services, or transfer of care, regardless of the reason; I am still responsible for full payment.
Pre-Natal Services comprise of the following:
1.Office visits, regardless of the number of visits, are included and free of charge.
2.Hospital delivery, regardless if vaginal or C-section, are included and equal in charge
3.Standard Blood Work Analysis and Cervical Cytology testing
4.Coordination of any complex medical conditions and events that develop
Excluded Services- services not covered by this agreement for which charges will be assigned by
Millennium Gynecology or a 3rd party
1.Non-standard blood work
2.Special genetic testing
3.Imaging studies such as Ultrasound
4.Emergency care in the hospital and prolonged hospitalization.
5.All Hospital costs and charges for pediatric, anesthesia, and subspecialist service
Millennium Pre-Natal Services Rates:
- $3,000.00 Paid in full [ ]
- $3,200.00 Paid in installments [ ]
a.$1,000 upon signing
b.$1,000 completed at 28weeks
c.$1,200 completed at 34 weeks
Supplemental Charges:
1.Circumcision $400.00
2.Tubal Ligation $500.00
General Rates for Excluded Services: * such rates are subject to change
** Please contact Keyna from Virginia Hospital Center to arrange a Self-Pay Contract for with the Hospital**
1. Hospital costs at Virginia Hospital Center
a.$3,000 1st night
b.$1,000 each additional night
i.There are no different charges for vaginal or C-section delivery
ii.To obtain such incredible rates, you must register online and take care of your hospital payment in your early 3rd trimester (28-32weeks)
2.Anesthesia Costs
a.Average $800/ epidural if requested by patient
By signing below, I the patient, understand and agree in full with the required payments and policies. If the patient is unable to commit to the payments set forth, the patient is encouraged to consider care at the OB/GYN clinic (InovaCares) or contact their local health department.
Patient Name______Witness Signature______
Patient Signature______Date______
Date______
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