Quotation Estimate Midwife in United States Chicago –Free Word Template Download with AI
1247 N. Michigan Avenue, Suite 300, Chicago, Illinois 60610, United States
Phone: (312) 555-0187 | Email: [email protected]
Illinois Midwifery License No. IL-MW-2024-08831 | NPI: 1740298356
Prepared For (Client)
Name: Mrs. Sarah Elizabeth Thompson
Address: 892 W. Fullerton Ave, Unit 4B, Chicago, IL 60614
Phone: (773) 555-0421
Email: [email protected]
Expected Due Date: March 15, 2026
Quotation Details
Quotation No.: QE-2025-CHIC-04472
Date Issued: January 12, 2025
Valid Until: February 12, 2025
Service Location: United States Chicago, Illinois
Prepared By: CNM Angela Rivera, Midwife
CONFIDENTIALDear Mrs. Thompson,
Thank you for selecting Lakeview Maternal Health & Midwifery Center for your prenatal, labor, and postpartum care. This Quotation Estimate outlines the comprehensive Midwife services we will provide to you throughout your pregnancy journey here in the United States Chicago metropolitan area. Our certified nurse-midwife team is dedicated to delivering personalized, evidence-based care that honors your birth preferences while ensuring the highest standards of maternal and neonatal safety.
Itemized Service Breakdown
| # | Service Description | Frequency / Qty | Unit Price (USD) | Subtotal (USD) | Notes |
|---|---|---|---|---|---|
| 1 | Initial Prenatal Consultation with Midwife (comprehensive history, physical exam, baseline labs) | 1 session | $285.00 | $285.00 | 90-minute visit |
| 2 | Routine Prenatal Visits (fundal height, BP, urine, fetal heart monitoring, counseling) | 10 visits | $195.00 | $1,950.00 | Monthly through 28 wks, biweekly through 36 wks, weekly after |
| 3 | Ultrasound Referral & Coordination (anatomy scan at 20 wks, growth scan at 32 wks) | 2 referrals | $320.00 | $640.00 | Performed at affiliated imaging center, Chicago |
| 4 | Labor & Delivery Attending Midwife (hospital or certified birth center in Chicago) | 1 event | $2,800.00 | $2,800.00 | Includes continuous one-on-one support |
| 5 | Postpartum Visits (maternal recovery, newborn assessment, lactation support) | 4 visits | $175.00 | $700.00 | Days 3, 14, 30, and 60 postpartum |
| 6 | Newborn Care Package (hearing screen coordination, vitamin K, jaundice monitoring, first immunization scheduling) | 1 package | $450.00 | $450.00 | Compliant with Illinois DOH guidelines |
| 7 | 24/7 On-Call Midwife Availability (phone consultation, urgent prenatal concerns) | Full term | $150.00 | $150.00 | Flat fee, unlimited calls |
| 8 | Birthing Class & Partner Preparation Workshop (held at our Chicago facility) | 1 session | $120.00 | $120.00 | 3-hour interactive class |
| 9 | Medical Records & Documentation Filing (Illinois state reporting, insurance billing coordination) | 1 service | $95.00 | $95.00 | Includes all lab work coordination |
| TOTAL ESTIMATED COST | $7,190.00 | ||||
Insurance & Payment Information
This Quotation Estimate reflects the full Midwife service fee schedule for our United States Chicago practice. We accept most major insurance carriers including Aetna, Cigna, UnitedHealthcare, Blue Cross Blue Shield of Illinois, and Medicaid (Illinois All Care). Our billing office will submit all claims on your behalf. The estimated out-of-pocket responsibility, based on your current plan's maternity benefit, is approximately $1,240.00 (deductible and co-pay). A 20% deposit of $1,438.00 is due upon acceptance of this Quotation Estimate to secure your Midwife assignment. The remaining balance is due within 30 days of delivery, payable in full or via our approved 0% interest installment plan over 6 months.
Terms & Conditions
- This Quotation Estimate is valid for 30 calendar days from the date of issue. After the expiration date, pricing may be adjusted to reflect current Midwife service rates in the United States Chicago healthcare market.
- All Midwife services are provided by a Certified Nurse-Midwife (CNM) licensed by the Illinois Department of Financial and Professional Regulation and certified by the American Midwifery Certification Board (AMCB).
- In the event of a medical emergency requiring transfer to an obstetrician or hospital-based intervention, additional fees will apply and are not included in this Quotation Estimate. You will be notified in writing prior to any such transfer.
- Client is responsible for providing accurate insurance information. Any changes to coverage during the term of care must be communicated to our billing office within 5 business days.
- Cancellation of scheduled Midwife appointments must be made at least 48 hours in advance to avoid a $75.00 no-show fee. Emergency cancellations due to medical necessity are exempt.
- All services are rendered in compliance with the Illinois Midwifery Practice Act (225 ILCS 65) and applicable federal regulations under the United States Department of Health and Human Services.
- This Quotation Estimate does not constitute a guarantee of a specific birth outcome. The Midwife will always prioritize the safety and well-being of both mother and newborn.
- Confidentiality of all medical records is maintained in accordance with HIPAA (Health Insurance Portability and Accountability Act) regulations.
Acceptance & Authorization
By signing below, the client acknowledges receipt and understanding of this Quotation Estimate for Midwife services in the United States Chicago area. The client agrees to the terms, conditions, and payment schedule outlined herein. The Midwife and Lakeview Maternal Health & Midwifery Center will assign a primary care provider within 5 business days of signed acceptance.
Client Signature & DateMrs. Sarah Elizabeth Thompson
Midwife / Authorized RepresentativeAngela Rivera, CNM – Lakeview Maternal Health & Midwifery Center
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