Today's Date *

MM

DD

YYYY

Full Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

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Prenatal Care Eligibility *

I understand Atlanta Birth Center (ABC) is a freestanding, out-of-hospital healthcare facility for low risk prenatal clients guided by the midwifery model of care with Certified Nurse Midwives. I understand that scheduling a COP visit with ABC does not mean I am a prenatal care client with ABC. I have read the FAQs page, and I understand a comprehensive clinical review of my health history will be required to determine eligibility for all prospective prenatal care clients. A COP visit is a separate stand-alone appointment.

I have read and understand the above statement.

Cost of my COP Appointment *

Our in-network insurance carriers are Amerigroup Medicaid, United Healthcare, and Aetna for office visits. If you have any of these insurances, please email the front and back of your insurance card to admin@atlantabirthcenter.org We will collect your copay for in-network insurance. If you have Amerigroup, we will NOT collect any out-of-pocket cost from you. If you have an out-of-network insurance or are self-pay, your visit will be $150. Please contact us if you need an income-based, financial assistance application.

I have read and understand the above statement.