The informed disclosure of practice form must be in writing and must contain the following information:

1. (1) A description of the certified direct entry midwife's education and training in midwifery, including completion of continuing education courses and participation in the peer review process.
2. (2) The certified direct entry midwife's experience level in the field of midwifery.
3. (3) The certified direct entry midwife's philosophy of practice.
4. (4) Antepartum, intrapartum, and postpartum period conditions requiring consultation, transfer of care, and transport to a hospital.
5. (5) The emergency medical backup plan, including the emergency plan and the collaborative agreement with a physician for backup care required under section 1 of this chapter.
6. (6) The services to be provided to the client by the certified direct entry midwife and that a physician is required to examine the client at least one (1) time during the client's first trimester and one (1) time during the client's third trimester.
7. (7) The certified direct entry midwife's current status of certification under this article.
8. (8) A detailed explanation of treatments and procedures.
9. (9) A detailed description of the risks and expected benefits of midwifery care.
10. (10) The availability of a grievance process in a case in which a client is dissatisfied with the performance of the certified direct entry midwife.

11. (11) A statement that if the client is advised by the certified direct entry midwife or a collaborating physician that the client is or has become at risk (as described in IC 25-23.4-6 ), the certified direct entry midwife:

    1. (A) shall refer the client to a physician for consultation;
    2. (B) may refuse to provide or continue care; and
    3. (C) may transfer care of the client to a physician.
12. (12) A statement disclosing whether or not the certified direct entry midwife maintains liability insurance.
13. (13) That state certification of a certified direct entry midwife does not ensure that a home setting for delivery of a child is safe.

14. (14) A statement that the client understands that the client is waiving the right to sue a physician or health care provider for the following:

    1. (A) The acts or omissions of the client's certified direct entry midwife.
    2. (B) For collaboration or work with a certified direct entry midwife except for in cases of gross negligence or willful or wanton misconduct by the physician or health care provider.

As added by P.L.232-2013, SEC.20. Amended by P.L.185-2015, SEC.23.