Michigan Medicaid Doula Initiative Agreement to Bill Insurance for Covered Services
The following agreement is hereby entered into between CHRISTIE DONN, MODERN MOTHER GODDESS LLC, referred to as “I,” and the client named and signed on this form, referred to as “you,” with the following conditions understood and accepted by both parties.
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I am so glad to be an approved member of the MDHHS Doula Registry, and be able to accept Michigan Medicaid Health Insurance. Please complete this form so that I can bill your insurance for services.
You can read more about this initiative on the Michigan Department of Health and Human Services website here. 
Michigan Medicaid coverage includes up to six prenatal and postpartum visits billed at $75 each, and $700 for attending the birth. 

Additional visits may be covered under your health plan with a written referral from your healthcare provider. In some instances, I may be able to authorize these visits directly with your health plan without the need for a separate referral. 

Per Michigan Medicaid guidelines, a visit must be at least 20 minutes in length in order to qualify. Visits spanning two calendar days may be billed as two separate visits. 

I agree to bill your Medicaid plan for services under these guidelines. If your insurance is not valid, or if the claim is denied because your allotted doula benefits were used by another provider you are working with, you may be responsible for all fees as described in this document at the Medicaid rates listed above. 

If you have other primary health insurance, I must submit my claims to your other insurance company first before the claim can be submitted to Medicaid. 

I will be transparent in my communications and make sure you are informed of the billing process. 

By completing this form, you understand that you may be responsible for payment if your insurance claim is denied.

Which Medicaid Health Plan do you have?
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Please enter all relevant information from your Medicaid insurance card including Plan name, Policy holder's name & date of birth, member ID, group number, etc. *
Do you have another health insurance plan? *
If you have another health insurance plan - Please enter all relevant information from your primary insurance card including Plan name, Policy holder's name & date of birth, member ID, group number, etc.
Please enter your mailing address.
By completing this form, you agree to allow me to submit claims to your health insurance plan as outlined above. You have read this contract describing the Michigan Medicaid Doula Initiative and agree to enter into a client-doula relationship for pregnancy and birth.
I, the undersigned, hereby certify and attest that I have sought guidance and/or support from the provider above. I therefore authorize the provider and personnel to release my or my minor child's medical information to the insurance company listed above for the purpose of determining and receiving benefits for doula services. 

I understand and acknowledge that the provider and staff will submit my claim to the insurance company on my behalf. I further understand that I will be held responsible for any amount of my bills not covered by my insurance policy or claims, and that I will be responsible for paying all deductibles, fees, co-payments, and co-insurance payments required. 

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided above. Non-compliance or defaulting on payments may result in denial of services and/or a legal claim against me for non-payment.

Please enter your information below and submit this form.
Your First and Last Name
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Your date of birth *
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Your Email
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Estimated Due Date
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By checking this box, you understand and agree that your typed name above will be accepted as your electronic signature on this contract.  *
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