Licensed Midwife Disclosure Form - Medical Board Of California printable pdf download

Licensed Midwife Disclosure Form - Medical Board Of California

LICENSED MIDWIFE DISCLOSURE FORM

Client: ______________________________________________ Date: __________________

Licensed midwife: _____________________________________ Date: __________________

Section 2508 of the Business and Professions Code requires that a licensed midwife shall make

the following disclosures in oral and written form.

1. All of the provisions of Section 2507 of the Business and Professions Code have been

explained to the client.

2. I understand that I am retaining the services of _____________________, who is a

licensed midwife, not a certified nurse midwife, and ______________________ is not

supervised by a physician and surgeon.

3. I understand that the license status of _______________________ is current and

unrestricted and his/her license number is _____________.

4. I understand that ____________________ practices in out-of-hospital settings, including

in homes, birth centers and clinics and does not have hospital privileges.

5. I understand that ____________________ does/does not have liability coverage for the

practice of midwifery. I also understand that many physicians and surgeons do not have

liability insurance coverage for services provided to someone having a planned out-of-

hospital birth.

6. I understand that if I am advised to consult with a physician and surgeon, failure to do so

may affect my legal rights in any professional negligence actions against a physician and

surgeon, licensed healthcare professional, or hospital.

7. I understand that there are conditions that are outside the scope of practice of a licensed

midwife that will result in a referral for a consultation from, or transfer of care to, a

physician and surgeon.

8. I understand that the specific arrangements for the referral of complications to a

physician and surgeon for consultation are:

________________________________________________________________________

Licensed Midwife Disclosure Form - Medical Board Of California