Informed Consent for Doula Health Services Via Telehealth or In-Person

DO NOT USE THIS SERVICE IF YOU MAY BE EXPERIENCING A MEDICAL EMERGENCY.

In an emergent situation, you can: (i) call 911; (ii) go to the nearest emergency room; (iii) contact your local crisis center; (iv) if applicable, call the National Suicide Prevention Lifeline (1-800-272-8255) ; or (v) if applicable, contact the Crisis Text Line (text "GO" to 741-741).

We are pleased you have chosen The Doula Network for your telehealth and/or in-person needs. This document is intended to inform you of what you can expect of your doula regarding their credentials and the non-clinical, emotional and educational support they may provide during your visits. After you have carefully read this document and have had an opportunity to have your questions answered, certain state laws mandate that you must sign and date it before commencing services.

IMPORTANT INFORMATION REGARDING YOUR CARE BY TELEHEALTH DOULAS, INCLUDING POTENTIAL RISKS AND BENEFITS.

The Doula Network offers non-clinical, emotional and educational support by doulas via telecommunications technology (also referred to as "telehealth") and in-person services. The services provided are discussed in further detail below. Where applicable, the electronic communication systems the doula uses will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. There are various benefits associated with telehealth services, including improved access to non-clinical, emotional and educational support by enabling you to remain in your home while the doula meets with you. Possible risks include delays in such non-clinical services could occur due to deficiencies or failures of the equipment and technologies, and in rare events, a doula may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth meeting or a meeting with your in-person licensed provider.

Limitations of Services

‍You understand that the doula is not here to make decisions, but to help you know your options. They will not perform any medical procedures, including, but not limited to, vaginal exams, listening to fetal heart tones, taking blood pressure, or any other clinical services. They will provide emotional and physical support only. They will not provide transportation for you due to liabilities. The doula will not make decisions for you. The doula will assist with getting information necessary for you to make informed decisions. The doula will not speak to the hospital or birth center or clinical staff on your behalf. The doula will discuss your concerns with you and suggest options, but you will be responsible for speaking to the hospital or birth center, and clinical staff directly.

Scope of Doula Services

The role of the doula is focused on providing non-clinical support to ensure comfort and emotional well-being through the prenatal, labor, and/or postpartum periods. Below are details of the specific services the doula will provide, as well as those they will not perform to ensure clarity on the scope of support offered.

What Doulas Will Do Your doula will:

• Provide care visits as outlined by the applicable state benefit program.
• Provide hands-on, emotional and educational support.
• Will help assist you in creating a birth plan.
• Work alongside your medical providers to support your birth plan and ensure you have non-clinical, emotional and physical support throughout the process.
• Provide non-clinical labor support and delivery support to you at a hospital or birth center, as requested.
• They will remain with you once active labor has begun and stay with you until 2 hours after the baby is born.
• The doula will utilize non-medical support techniques for labor and birth.
• They will strive to maintain a calm and peaceful birth environment.
• Photograph labor, birth and recovery as allowed by the hospital or birth center, and if desired by you, using only your camera or phone.
• As covered by your health benefit program, after the birth, assist in giving information and emotional support during at least 2 in-person postpartum visits within the first 6 weeks after the birth.

Your doula will not:

• Provide any clinical care, including but not limited to, performing any medical procedures, such as, administering medications, conducting physical examinations, providing any invasive care, or replacing medical personnel whether at home or in a hospital or birth center.
• Provide any medical advice or diagnose any medical issues.
• Make any decisions for you.
• Represent that they hold any professional licensure that would otherwise authorize them to perform medical or clinical services.
• Attend a home birth.

Client Obligations

For prenatal, labor, and postpartum support, you understand it is your responsibility to:

• As covered by your health benefit program, schedule and attend 2 (or more) prenatal appointments with your doula either at your home or a mutually chosen location.
• Keep the doula informed of any issues, progress, or changes to your pregnancy.
• Call your doula when labor begins so they can make plans to attend your birth even if you are not ready to go to the hospital or birth center. Please allow at least 1-2 hours for your doula's travel time. Your doula will evaluate the situation and decide the best location to meet, whether at your home or directly at the hospital or birth center, based on their non-clinical assessment of your progress and safety.
• Notify your doula of any insurance changes prior to any visits.
• Inform your medical provider that you want a birth doula at your birth.
• Read and sign all agreements.

For postpartum only support, you understand it is your responsibility to:

• As covered by your health benefit program, schedule and attend 2 (or more) postpartum visits with your doula either at your home or a mutually chosen location.
• Keep the doula informed of any issues, progress, or changes to your postpartum condition and/or needs.
• Notify your doula of any insurance changes prior to any visits.
• Read and sign all agreements.

YOUR TELEHEALTH DOULA'S CREDENTIALS

Your doula's credentials were made available to you before scheduling a visit. If you have any questions about these credentials, please direct them to your doula. For those states that require it, you can find an explanation of the levels of regulation applicable to telehealth doulas, including coordination with your primary care provider under the STATE REGULATIONS section of this document.

By checking the Box associated with "Informed Consent", you are representing that you have read this document and understand the information found in it. At times, your doula may seek supervision or consultation with other The Doula Network or non-The Doula Network doulas or providers regarding your treatment, to enhance the services being provided to you given the multiple perspectives, experiences, and treatment philosophies. All team members are ethically and legally bound to maintain your privacy and confidentiality in this scenario and none of your personal information will be shared or disclosed with any other individual without your consent.

Exceptions to confidentiality do exist in certain situations, such as: threat of serious harm to self or others ; reasonable suspicion of abuse or neglect of a child, or abuse, neglect, or exploitation of an incapacitated or dependent adult ; court order and/or subpoena; permission from you or your guardian (i.e. voluntary release signed by you or your guardian) ; during supervisory consultations; diagnosis and dates of service shared with an insurance company to collect payments ; information released as outlined in Pomelo Care's Notice of Privacy Practices (https://www.pomelocare.com/terms-policies) and Privacy Policy (https://www.pomelocare.com/terms-policies) ; and as otherwise required by law.

CARE AND CONFIDENTIALITY OF MINORS

You understand that your doula will provide care to you, if you are a minor, consistent with the laws in the state in which you are located.

FEES AND BILLING ARRANGEMENTS

As applicable, you agree to pay The Doula Network all applicable charges at the prices then in effect for the doula services provided to you or another person on whose behalf you are accepting the terms contained in this consent, such as children (each, a "Covered Family Member"). You will be charged for the doula services provided to you or your Covered Family Member by The Doula Network. You authorize The Doula Network and its agents, partners, and third-party services providers to charge your chosen payment method ("Payment Method") for the doula services provided to you or your Covered Family Member. If your Payment Method is invalid at the time payment is due, you agree to pay all amounts due upon demand. The third-party services provider who manages your Payment Method may impose terms and conditions on you, which are independent of the terms contained in this consent, and you agree to comply with those terms. The Doula Network and their agents, as applicable, reserve the right to correct any billing errors or mistakes even if payment has already been requested or received. Payment in full is due when the doula services are first delivered. No refunds will be issued if the doula services are terminated.

ASSIGNMENT OF BENEFITS

You hereby authorize the direct payment to The Doula Network of all insurance and plan benefits, including Commercial, Medicaid and/or Tricare, otherwise payable to or on your behalf for services rendered by your doula. If you receive payment directly from your insurance company or third-party payer, you agree to immediately forward to The Doula Network all healthcare-care related payments you receive for services provided by the doula. You consent to any request for review or appeal by The Doula Network, its associates or agents, to challenge a determination of benefit made by your insurance carrier or third-party payer.

By checking the box associated with "Informed Consent", you acknowledge that you understand and agree with the following:

1. You hereby consent to receiving The Doula Network's services via telehealth technologies and/or in-person. You understand that The Doula Network and its doulas offer telehealth-based and in-person services, but that these services do not replace the relationship between you and your medical provider. You also understand it is up to The Doula Network doula to determine whether or not your specific non-clinical needs are appropriate for a telehealth encounter. At any time, either the doula or you may terminate these services. You understand the doula's role in labor and birth and understand that they will not perform any medical procedures or clinical services.
2. You have been given an opportunity to select a doula from The Doula Network prior to the visit, including a review of their credentials.
3. You acknowledge that you have received Pomelo Care's Notice of Privacy Practice, which describes the ways in which Pomelo Care and its subsidiaries including The Doula Network may use and disclose your health information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures. You understand that you may contact the individual designated on the notice if you have a question or complaint. You understand that your health information may be disclosed electronically by The Doula Network and/or The Doula Network's business associates. If your consent is required by law, you agree to the use and disclosure of your health information for the purposes described in the Notice of Privacy Practice to the extent permitted by law.
4. You agree that all telephone numbers and email addresses you provide to The Doula Network may be used by The Doula Network or those acting on its behalf to communicate with you about your doula services and relationship with The Doula Network by telephone (including cell phone), unencrypted text messages, unencrypted email, or any automated or prerecorded messages. You understand that unencrypted communications may be intercepted by unauthorized individuals and you understand and accept the risk of using unencrypted communications. If you do not want to receive unencrypted communications or phone calls, then you can email client_support@pomelocare.com and ask to be removed from the list.
5. You understand there is a risk of technical failures during the telehealth encounter beyond the control of The Doula Network. You agree to hold harmless The Doula Network for delays in evaluation or for information lost due to such technical failures.
6. You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care. You understand that you may suspend or terminate use of the telehealth services at any time for any reason or for no reason. You understand that if you are experiencing a medical emergency, that you will be directed to dial 9-1-1 immediately and that The Doula Network doulas are not able to connect you directly to any local emergency services.
7. You understand that alternatives to telehealth consultation, such as in-person services are available to you.
8. You understand that you may expect the anticipated benefits from the use of telehealth in your care, but that no results can be guaranteed or assured.
9. You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the visit other than The Doula Network provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the visit and thus will have the right to request the following: (a) omit specific details of your medical history/examination that are personally sensitive to you; (b) ask non-medical personnel to leave the telehealth examination ; and/or (c) terminate the visit at any time.
10. You understand that you will not be prescribed any narcotics, nor is there any guarantee that you will be given a prescription at all.
11. You understand that if you participate in a visit, that you have the right to request a copy of your records which will be provided to you at reasonable cost of preparation, shipping and delivery.
12. You acknowledge that you have discussed and reviewed your wishes for birth doula support with your medical healthcare provider, the doula and The Doula Network. You understand that in planning for your baby's birth, the doula cannot ensure that the birth will go as you plan but will be there to support you. As covered by your health benefit program, the doula agrees to provide a scope of prenatal, labor and/or postpartum support for you, as discussed above in this consent.
13. Unforeseen circumstances may prevent the doula from attending part of or the entirety of your birth. The doula will inform you of times when they are unavailable. If the doula cannot attend, The Doula Network will make best efforts to arrange for a back up doula, credentialed by The Doula Network.
14. You understand that your doula may be trained and certified to offer additional services such as childbirth education, placenta encapsulation, essential oils, TENS or other named services. By accepting birth doula services from The Doula Network you are in no way obligated to purchase any additional services from your doula. Your decision to accept or refuse additional services, or their associated costs, will in no way impact the birth doula services you are provided as a benefit of your insurance. For the avoidance of doubt, none of the foregoing mentioned services are offered, provided or endorsed by The Doula Network and any arrangement for such additional services are solely between you and your doula.
15. You have read and you understand the disclosures set forth next to the state in which you are located at the time of the telehealth encounter, as set forth below:

STATE REGULATIONS (State-specific regulations listed as in original document)

• Alaska: You understand your primary care provider may obtain a copy of your records of your telehealth encounter. (Alaska Stat. § 08.63.210(C)(2) .
• Arizona: You understand that all medical records resulting from a telemedicine consultation are part of your medical record. (Ariz. Rev. Stat. Ann. § 36-3602(D)).
• California: You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment, or, affecting your ability to access covered services from Medi-Cal in the future. You understand that you have the right to access Medi-Cal covered services through an in-person, face-to-face visit or through telehealth. You understand that Medi-Cal provides coverage for transportation services to in-person services when other resources have been reasonably exhausted. (Cal. Welf. & Inst. Code Ann. § 14132.725(d)).
• Connecticut: You understand that your primary care provider may obtain a copy of your records of your telehealth encounter, and that you can revoke your consent at any time. (Conn. Gen. Stat. Ann. § 19a-906) .
• D.C.: You have been informed of alternate forms of communication between you and a physician for urgent matters. (D.C. Mun. Regs. tit. 17, § 4618.10) . Relevant communications with the physician, including those done via electronic methods shall be documented and filed in your medical record. (D.C. Mun. Regs. tit. 17, § 4618.9) .
• Georgia: You have been given clear, appropriate, accurate instructions on follow-up in the event of needed emergent care related to the treatment. (Ga. Comp. R. & Regs. 360-3-.07(7)).
• Idaho: You further understand that your informed consent for the use of telehealth services shall be obtained by applicable law. Idaho Statutes 54-5708.
• Indiana: If a prescription is issued to you, and subject to your consent the prescriber shall notify your primary care provider of any prescriptions the prescriber has issued for you if the primary care provider's contact information is provided by you. This requirement does not apply if: (A) The practitioner is using an electronic health record system that your primary care provider is authorized to access. (B) The practitioner has established an ongoing provider-patient relationship with the patient by providing care to the patient at least 2 consecutive times through the use of telehealth services. If the conditions of this clause are met, the practitioner shall maintain a medical record for you and shall notify your primary care provider of any issued prescriptions. Ind. Code Ann. 25-1-9.5-7. If you are a Medicaid patient, you have the right to choose between an in-person visit or telehealth visit. Indiana Medicaid Manual: Telehealth and Virtual Services.
• Iowa: As appropriate your provider will identify the medical home or treating physician(s) for you, when available, where in-person services can be delivered in coordination with the telemedicine services. Your provider shall provide a copy of the medical record to your medical home or treating physician(s). Iowa Admin. Code 653-13.11(147,148,272C)(13.11(11)).
• Kansas: You understand that if you have a primary care provider or other treating physician, the person providing telemedicine services must send within three business days a report to such primary care or other treating physician of the treatment and services rendered to you during the telemedicine encounter. (Kan. Stat. Ann. § 40-2,212(2)(d)(2)(A) .
• Kentucky: If requested by you, your provider must share the medical record with your primary care physician and other relevant members of your existing care team. Kentucky Board Opinion on the Use of Telemedicine Technologies (2014), as amended September 15, 2022.
• Louisiana: You understand the role of other health care providers that may be present during the consultation other than the telehealth provider. (46 La. Admin. Code Pt XLV, § 7511) .
• Nebraska: If you are a Medicaid recipient, you retain the option to refuse the telehealth consultation at any time without affecting your right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled. All existing confidentiality protections shall apply to the telehealth consultation. You shall have access to all medical information resulting from the telehealth consultation as provided by law for access to your medical records. Dissemination of any patient identifiable images or information from the telehealth consultation to researchers or other entities shall not occur without your written consent. You understand that you have the right to request an in-person consult immediately after the telehealth consult and you will be informed if such consult is not available. (Neb. Rev. Stat. Ann. § 71-8505; 471 Neb. Admin. Code § 1-006.05) .
• New Hampshire: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. (N.H. Rev. Stat. § 329:1-d) .
• New Jersey: You understand that you have the right to request a copy of your medical information and you understand your medical information may be forwarded directly to your primary care provider or health care provider of record, or upon your request, to other health care providers. If you do not have a primary care provider or other health care provider of record, the health care provider engaging in telemedicine or telehealth may advise you to contact a primary care provider, and, upon request by you, may assist you with locating a primary care provider or other in-person medical assistance that, to the extent possible, located within reasonable proximity to you. N.J. Rev. Stat. Ann. § 45:1-62.
• Ohio: You understand that the telehealth provider may forward your medical records to your primary care or treating provider. Ohio Admin. Code 4731-37-01(C)(4).
• Rhode Island: If you use e-mail or text-based technology to communicate with your provider, then you understand the types of transmissions that will be permitted and the circumstances when alternate forms of communication or office visits should be utilized. You have also discussed security measures, such as encryption of data, password protected screen savers and data files, or utilization of other reliable authentication techniques, as well as potential risks to privacy. You acknowledge that your failure to comply with this agreement may result in the telehealth provider terminating the relationship. (Rhode Island Medical Board Guidelines) .
• South Carolina: You understand your medical records may be distributed in accordance with applicable law and regulation to other treating health care practitioners. You understand the value of having a primary care medical home and, if requested, we can provide assistance in identifying available options for a primary care medical home. S.C. Code Ann. § 40-47-37. You also understand that if you are a Medicaid beneficiary, you can withdraw your consent at any time. South Carolina Health and Human Svcs. Dept. Physicians Provider Manual, p. 35 (Feb. 2024).
• South Dakota: You have received disclosures regarding the delivery models and treatment methods or limitations. You have discussed with the telehealth provider the diagnosis and its evidentiary basis, and the risks and benefits of various treatment options. (S.D. Codified Laws § 34-52-3) .
• Texas: You understand that your medical records may be sent to your primary care physician within 72 hours. Tex. Occ. Code Ann. § 111.005.
• Utah: You are able to a (i) access, supplement, and amend your patient-provided personal health information; (ii) contact your provider for subsequent care; (iii) obtain upon request an electronic or hard copy of your medical record documenting the telemedicine services, including the informed consent provided ; and (iv) request a transfer to another provider of your medical record documenting the telemedicine services. Utah Admin. Code r. 156-1-602.
• Virginia: You acknowledge that you have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; You agree to hold harmless The Doula Network for information lost due to technical failures ; and you provide your express consent to forward patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12) .
• Vermont: You understand that you have the right to receive a consult with a distant-site provider and will receive one upon request immediately or within a reasonable time after the results of the initial consult. You understand that receiving telehealth services via store-and-forward technologies by The Doula Network does not preclude you from receiving real-time telemedicine or face-to-face services with the distant provider at a future date. (Vt. Stat. Ann. § 9361) .

You have read this document carefully, and understand the risks and benefits of the telehealth and in-person services and have had your questions regarding the services explained and you hereby give your informed consent to participate in telehealth and in-person visits under the terms described herein.

‍

ACCEPT

‍By checking the box associated with "Informed Consent", you hereby state that you have read, understood, and agree to the terms of this document.

Release from Liability

By signing this release of liability ("Agreement") for birth doula services, I, [PATIENT'S NAME], acknowledge that services may be provided in my home, or while traveling to a medical facility, such as a birth center, or hospital. I understand that the doula has a limited role pursuant to the description of tasks outlined in their independent contractor agreement.

The doula has not represented or guaranteed to me that by agreeing to birth doula services, I will have a risk-free or emergency-free labor and birth experience. I understand that the doula does not make any clinical, medical or nursing decisions on my behalf, including, but not limited to, decisions regarding when to seek medical care or when to proceed to a hospital or birth center. I agree that the role of the doula is strictly limited to providing non-clinical, emotional and physical support during the prenatal, labor, and postpartum periods. In addition, I agree that the doula does not perform clinical assessments, administer medical treatments, offer medical advice, or act as a medical professional at any time.

When services are performed in a medical facility, such as a hospital or birth center, I acknowledge that the doula is not responsible for the performance of clinical tasks which include medical or nursing decisions regarding the inclusion or exclusion of treatments available to the baby or me.

Therefore, in consideration of the above acknowledgements, I, on behalf of myself, my heirs, administrators, personal representatives, executors, assigns, and any other parties, release and forever discharge, the doula, The Doula Network, and Pomelo Care, Inc., and its associated professional corporations, from any and all claims, damages, or causes of action, whether at law or in equity, which I may have or acquire, or that may accrue to me, my heirs, administrators, personal representatives, executors, assigns, or any other parties, as a result of receiving services from the doula.

I intend this Agreement to be a complete and final discharge of any and all liability. I have read and fully understand all statements contained herein, and I acknowledge that by signing this Agreement, I have or may believe I have arising from my use of the doula services.

‍

CONTACT US

‍If you have questions or need further assistance regarding this Notice, you may contact our Privacy Officer at

‍

The Doula Network

169 Madison Avenue, Suite 11549

New York, NY 10016

or by email to privacy-inquiries@pomelocare.com