International Obstetrics Professional Courtesy Program

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1 Plan 1: Pregnancy (28 weeks and below) METHOD OF DELIVERY: FEE INCLUDES: PATIENT REQUIREMENTS: Vaginal Delivery [$1700] Trial of Labor after Cesarean Section [$2700] Package includes Surgical Assistant & fee if Cesarean Section is repeated. Repeat Cesarean Section [$1700] Package includes Surgical Assistant fee. 10 office appointments. $50 per appointment exceeding 10. Prenatal Ultrasounds. Additional ultrasounds following Consultation Ultrasound will cost $100 per ultrasound. Patient must provide the results of all required labs: Complete Metabolic Panel CBC with platelets Group and Rh factor Antibody Screen Rubella Hepatitis Surface Antigen HIV Screen Herpes Type 1 and 2 Screen Alpha Fetoprotein 4 Screen (AFP-4) Pap Smear and HPV Screen Gonorrhea and Chlamydia Cervical Cultures or PCR Radiology Reports are required Glucose Challenge Test (1 hour GCT). Group B Strep Culture (GBS). Delivery & two postpartum visits Additional postpartum visits will cost $50 per visit. Patient must have had at least one complete OB ultrasound done at approximately 20 weeks for anatomical evaluation. PAYMENT SCHEDULE: $150 Initial Consultation Fee. Not part of the Contract Fee. Full Payment must be made by 30 weeks. Patient has a separate financial obligation with the hospital. Patient must agree to deliver at Sierra Medical Center. Patient has a separate financial obligation with the Pediatrician. Contract Fee is nonrefundable. lan 1: Pregnancy

2 Plan 1: Embarazo (0 a 28 semanas) MÉTODO DE PARTO: EL PAGO INCLUYE: REQUISITOS DE PACIENTE Parto Vaginal [$1700] Proceso de Trajo de Parto después de una Cesarea [$2700] El paquete incluye el pago del Asistente Quirúrgico si la Cesarea es repetida. Cesarea Repetida [$1700] El paquete incluye el pago del Asistente Quirúrgico. 10 citas prenatales en la oficina. Adicionales visitas prenatales costaría $50 por cita. Ultrasonido prenatales. Los ultrasonidos adicionales después de Ultrasonido de Consulta costarán $100 por ultrasonido. Ella debe proveer los siguiente resultados de laboratorio: Panel metabólica Completo CBC con plaquetas Grupo y Factor Rh Prueba de Anticuerpo Rubéola Antigeno Hepatitis Superficial Detección de anticuerpos del VIH Detección de Herpes Tipo 1 y 2 Análisis Fetoproteína Alpha 4 Papanicolau y detección de HPV Gonorrea y Cultivo de tejidos Clamidia Cervical o PCR Prueba de tolerancia oral a la glucosa (GCT) Prueba Estreptococos Grupo B Un reporte de Radiología es requerido. Parto y dos visitas después del parto. Visitas adicionales después del parto costaría $50 por visita. La paciente debe haber completado un ultrasonido OB aproximadamente a los 20 semanas para un evaluación anatómico. PLAN DE PAGO: $150 Pago de Consulta Inicial. No forma parte del precio de contrato. El Pago total debe ser hecho antes de 30 semanas. obligación financial separada con el Hospital. La paciente debe acceder a dar luz en Sierra Medical Center. obligación separada con el Pediatra. Tarifa del contrato no es reembolsable. Plan 1: Embarazo

3 Plan 2: Pregnancy [ weeks ] METHOD OF DELIVERY: FEE INCLUDES: PATIENT REQUIREMENTS: Vaginal Delivery [$1700] Trial of Labor after Cesarean Section [$2700] Package includes Surgical Assistant & fee if Cesarean Section is repeated. Repeat Cesarean Section [$1700] Package includes Surgical Assistant fee. 10 office appointments. $50 per appointment exceeding 10. Patient must have been followed by a licensed physician from the 20 week to 28 week of pregnancy. Patient must provide the results of all required labs: Complete Metabolic Panel CBC with platelets Group and Rh factor Antibody Screen Rubella Hepatitis Surface Antigen HIV Screen Herpes Type 1 and 2 Screen Alpha Fetoprotein 4 Screen (AFP-4) Pap Smear and HPV Screen Gonorrhea and Chlamydia Cervical Cultures or PCR Radiology Reports are required Glucose Challenge Test (1 hour GCT). Group B Strep Culture (GBS). Delivery & two postpartum visits Additional postpartum visits will cost $50 per visit. Patient must have had at least one complete OB ultrasound done at approximately 20 weeks for anatomical evaluation. PAYMENT SCHEDULE: $150 Initial Consultation Fee. Not part of the Contract Fee. Full Payment must be made by 30 weeks. Patient has a separate financial obligation with the hospital. Patient must agree to deliver at Sierra Medical Center. Patient has a separate financial obligation with the Pediatrician. Contract Fee is nonrefundable. lan 2: Pregnancy

4 Plan 2: Embarazo [ 29 a 36 semanas ] MÉTODO DE PARTO: EL PAGO INCLUYE: REQUISITOS DE PACIENTE Parto Vaginal [$1700] Proceso de Trajo de Parto después de una Cesarea [$2700] El paquete incluye el pago del Asistente Quirúrgico si la Cesarea es repetida. Cesarea Repetida [$1700] El paquete incluye el pago del Asistente Quirúrgico. 10 citas prenatales en la oficina. Adicionales visitas prenatales costaría $50 por cita. La paciente debe ser bajo el cuidado de un Medico Certificado dentro las 20 a 28 semanas de embarazo. Ella debe proveer los siguiente resultados de laboratorio: Panel metabólica Completo CBC con plaquetas Grupo y Factor Rh Prueba de Anticuerpo Rubéola Antigeno Hepatitis Superficial Detección de anticuerpos del VIH Detección de Herpes Tipo 1 y 2 Análisis Fetoproteína Alpha 4 Papanicolau y detección de HPV Gonorrea y Cultivo de tejidos Clamidia Cervical o PCR Prueba de tolerancia oral a la glucosa (GCT) Prueba Estreptococos Grupo B Un reporte de Radiología es requerido. Parto y dos visitas después del parto. Visitas adicionales después del parto costaría $50 por visita. La paciente debe haber completado un ultrasonido OB aproximadamente a los 20 semanas para un evaluación anatómico. PLAN DE PAGO: $150 Pago de Consulta Inicial. No forma parte del precio de contrato. El Pago total debe ser hecho antes de 30 semanas. obligación financial separada con el Hospital. La paciente debe acceder a dar luz en Sierra Medical Center. obligación separada con el Pediatra. Tarifa del contrato no es reembolsable. Plan 2: Embarazo

5 Plan 3: Pregnancy [ 37 weeks and above ] METHOD OF DELIVERY: FEE INCLUDES: PATIENT REQUIREMENTS: Vaginal Delivery [$1700] Trial of Labor after Cesarean Section [$2700] Package includes Surgical Assistant & fee if Cesarean Section is repeated. Repeat Cesarean Section [$1700] Package includes Surgical Assistant fee. 4 office appointments. 4 office appointments ($50 per appointment exceeding 4). Patient must have been followed by a licensed physician from the 20 week to 37 week of pregnancy. Patient must provide the results of all required labs: Complete Metabolic Panel CBC with platelets Group and Rh factor Antibody Screen Rubella Hepatitis Surface Antigen HIV Screen Herpes Type 1 and 2 Screen Alpha Fetoprotein 4 Screen (AFP-4) Pap Smear and HPV Screen Gonorrhea and Chlamydia Cervical Cultures or PCR Radiology Reports are required Glucose Challenge Test (1 hour GCT). Group B Strep Culture (GBS). Delivery & two postpartum visits Additional postpartum visits will cost $50 per visit. Patient must have had at least one complete OB ultrasound done at approximately 20 weeks for anatomical evaluation. PAYMENT SCHEDULE: $150 Initial Consultation Fee. Not part of the Contract Fee. Full Payment must be made by 37 weeks. Patient has a separate financial obligation with the hospital. Patient must agree to deliver at Sierra Medical Center. Patient has a separate financial obligation with the Pediatrician. Contract Fee is nonrefundable. lan 3: Pregnancy

6 Plan 3: Embarazo [ 37 semanas y adelante ] MÉTODO DE PARTO: EL PAGO INCLUYE: REQUISITOS DE PACIENTE Parto Vaginal [$1700] Proceso de Trajo de Parto después de una Cesarea [$2700] El paquete incluye el pago del Asistente Quirúrgico si la Cesarea es repetida. Cesarea Repetida [$1700] El paquete incluye el pago del Asistente Quirúrgico. 4 citas prenatales en la oficina. Adicionales visitas prenatales costaría $50 por cita. La paciente debe ser bajo el cuidado de un Medico Certificado dentro las 20 a 37 semanas de embarazo. Ella debe proveer los siguiente resultados de laboratorio: Panel metabólica Completo CBC con plaquetas Grupo y Factor Rh Prueba de Anticuerpo Rubéola Antigeno Hepatitis Superficial Detección de anticuerpos del VIH Detección de Herpes Tipo 1 y 2 Análisis Fetoproteína Alpha 4 Papanicolau y detección de HPV Gonorrea y Cultivo de tejidos Clamidia Cervical o PCR Prueba de tolerancia oral a la glucosa (GCT) Prueba Estreptococos Grupo B Un reporte de Radiología es requerido. Parto y dos visitas después del parto. Visitas adicionales después del parto costaría $50 por visita. La paciente debe haber completado un ultrasonido OB aproximadamente a los 20 semanas para un evaluación anatómico. PLAN DE PAGO: $150 Pago de Consulta Inicial. No forma parte del precio de contrato. El Pago total debe ser hecho antes de 37 semanas. obligación financial separada con el Hospital. La paciente debe acceder a dar luz en Sierra Medical Center. obligación separada con el Pediatra. Tarifa del contrato no es reembolsable. Plan 3: Embarazo

7 Contract C O NT R A CT A G RE E M EN T Terms I am requesting to establish a Physician-Patient relationship with Dr. Novoa. I agree to be co-managed by Dr. Novoa and my current physician, Dr.. Method of Delivery I understand that this Plan requires the cash payment of: $1,700 for a Vaginal Delivery, $2,700 for a Trial of Labor after Cesarean Section (TOLAC), and $1,700 for a Repeat Cesarean Section. I understand that this fee includes the following: (10) prenatal office appointments. Additional prenatal visits will cost $50 per appointment. (1) Delivery visit. (2) postpartum visits. Additional postpartum appointments will cost $50 per visit. I understand that the following Prenatal labs are required but IS NOT included in this contract agreement: Complete Metabolic Panel (CMP) CBC with platelets Group and Rh Antibody Screen Rubella VDRL, STS or RPR Hepatitis Surface Antigen HIV Alpha Fetoprotein 4 Screen (AFP-4) Pap Smear and HPV Screen Gonorrhea and Chlamydia Cervical Cultures or PCR Glucose Challege Test (1 hour GCT) Group B Strep Screen I understand that the following tests are optional and IS NOT included in this contract agreement: Herpes 1 and 2 Screen Cystic Fibrosis Additional Fees $100 charge for each ultrasound. $150 for each emergency hospital evaluation not associated with delivery. $100 for Biophysical Profiles and Non Stress Tests not covered under the 10 prenatal office visits. If necessary. Patient has a separate financial obligation with the Hospital and Pediatrician. Prenatal labs are charged separately and patient is responsible for all lab fees. Payment Schedule $150 Initial Consultation Fee. (Not part of contract fee) $500 Initial Deposit which includes payment for prenatal labs and OB ultrasound. $100 towards balance for each additional appointment up to 30 week. Contract balance must be paid by 30 weeks. $150 for any Emergency hospital evaluation must be paid at the next office visit. Refunds This contract agreement is nonrefundable. Name of Patient Provider Chief Financial Officer

8 Contract A C U E R D O D E C O N T R A T O Términos Estoy solicitando a establecer una relación médico-paciente con el Dr. Novoa. Me comprometo a ser co-dirigida por el Dr. Novoa y mi médico actual, Dr.. Método de Entrega Entiendo que este Plan requiere el pago en efectivo de: $1,700 para un Parto Vaginal. $2,700 Proceso de Trajo de Parto despues de una Cesarea, y $1,700 para una Cesarea Repetida. Entiendo que esta tarifa incluye los siguientes: (10) citas prenatales en la oficina. Adicionales visitas prenatales costaria $50 por cita. (1) visita de parto. (2) visitas postparto. Citas postparto adicionales costará $50 por visita. Entiendo que los análisis prenatales siguientes son necesarios pero no está incluida en este contrato: Panel metabolica completo (CMP) CBC con plaquetas Grupo y Factor Rh Prueba por anticuerpos Rubeola VDRL, STS o RPR Antígeno Hepatitis Superficial Detección de anticuerpos del VIH Análisis Fetoproteína Alpha 4 (AFP-4) Papanicolau y detección de HPV Gonorrea y clamidia Culturas cervicales o PCR Prueba de tolerancia oral a la glucosa Prueba Estreptococos Grupo B Entiendo que los siguientes exámenes son opcionales y no está incluida en este contrato: Detección de Herpes Tipo 1 y 2 Cystic Fibrosis Cargos adicionales $100 por cada ultrasonido. $150 por cada evaluación de emergencia del hospital no asociado con la entrega. $100 para perfiles biofísicos y sin pruebas de estrés no cubiertos por las 10 visitas al consultorio prenatal. Si es necesario. El paciente tiene una obligación financiera separada con el Hospital y el pediatra. Laboratorios prenatales se cobran por separado y el paciente es responsable por todos los gastos de laboratorio. a de pagos $150 Pago de Consulta Inicial. (No forma parte del contrato tarifa) $500 deposito Initial que incluye pago para ultrasonido prenatales y los analisis prenatales. $100 por cada cita adicional hasta 30 semanas. El balancia del contrato debe ser pagado antes de 30 semanas. $150 para cualquier evaluación del hospital de Emergencia se deben pagar en la siguiente visita de la oficina. Reembolso Este contrato no es reembolsable. Name of Patient Provider Chief Financial Officer

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