Dr Elly Green

Your obstetrician has asked me to be responsible for your baby's medical care. You must be about to have a baby (or perhaps two) or maybe you've already had one. Either way, congratulations! I look forward to meeting you at this happy time. I am Dr Elly Green, a paediatrician with particular expertise in the medical care of newborn babies.

The link below, provides important information about my service as well as the normal events in the first week of your baby's life. Please read the information found when you follow the link below and write down any questions you have (I understand that you'll be tired after the birth). I can answer your questions in the days after the birth.

Link to further information: Patient Information

Please take a few minutes to complete the remainder of this form. Knowing about your health, and about any problems during the pregnancy is important; it allows me to provide the best possible care to you and your baby. After completing this form, there is important information about the cost of my service. It is important to me that you are aware of my fees so I can care for your baby with your informed financial consent. I am very happy to answer any questions about my fees.

Baby's name

Leave blank if you haven't decided on one yet!

First Name

Last Name

Mother's name

First Name

Last Name

Email address

Please enter an address you will be regularly checking as we will use this as the primary means of communicating with you about your baby's paediatric care.

Mobile

Partner's name

First Name

Last Name

GP Name

First Name

Last Name

Clinic Name

GP Address

Address

Suburb

GP Phone Number

Please enter your family Medicare number below

Is there a family history of childhood problems?

Hip dysplasia

Heart disease

Congenital cataracts

Other

Were there any complications during this pregnancy?

Thyroid disease

Breech position (baby bottom first)

Other

Were there any abnormalities on your ultrasound scans? If you selected 'other' above please provide any further details in this section

Were you taking any medication during the pregnancy?

Vitamin D supplements

Other

Fees and Charges:

I am not paid by the hospital and there are out of pocket costs (also called a 'gap' fee) associated with my care of your baby. An invoice for my services will be emailed to you after your baby has been discharged home.

My fees are detailed below. The cost of my attendance varies depending on both circumstances and timing. Urgent attendances are associated with higher fees; so are out-of-hours attendances as I will have been called in from home. Hospital fees are more expensive than visits to a specialist in their consulting rooms. This is because my colleagues and I provide a 24-hour service taking calls from the midwifery staff if they are concerned about your baby. In addition, one of us is always available to attend urgently if there is an emergency. There is no separate cost for this around the clock medical cover for your baby; it is factored into my overall fees.

You can claim the Medicare benefit component of my fees once your baby has been added to your Medicare card. Your health fund will not contribute to the gap fee if your baby remains on the postnatal ward as the baby is considered an outpatient of the hospital. If you have reached your the medicare safety net Medicare will refund 80% of the gap fee (up to a safety net cap) for these outpatient services.

If your baby is admitted to Special Care Nursery, or receives phototherapy for jaundice on the postnatal ward with you, both Medicare and your health fund will contribute to the gap fee.

Initial attendance fees

	Billed amount	Medicare rebate	Gap after medicare	Gap with safety net
Routine attendance (in hours)	$450	$143.35	$306.65	$52.47
Elective c-section (in hours)	$520	$143.35	$376.65	$72.47
Emergency attendance in hours or Elective c-section out of hours	$600	$143.35	$456.65	$92.47
Evening or weekend emergency attendance	$700	$143.35	$556.65	$112.47
Evening or weekend emergency attendance with call in from home	$750	$143.35	$606.65	$176.65
Overnight emergency attendance with call in from home	$800	$143.35	$656.65	$376.65

In hours: 7.30am to 5pm weekdays

Out of hours: 5pm to 7.30am weekdays, all public holidays and weekends

Subsequent Attendance Fees:

Following the initial visit, I will come and check on your baby each day during your hospital stay (unless you and your baby are well enough to be transferred to the Park Hyatt); this is to check for jaundice and to work with the midwifery staff on your baby's feeding plan. If I am away, or unavailable, one of the other paediatricians in our practice will cover for me and visit instead. If this is the case, you will also receive a bill from them.

You will be charged $200 for your baby's discharge check (performed the day before you go home), and on other occasions when there is a full clinical review. The Medicare rebate for these consultations is $68.90. Other subsequent attendances are charged at $81.05 or $46.15 depending on the level of complexity; the Medicare rebates for these consultations are $68.90 (Item 116) and $39.25 (Item 119) respectively.

Hospital fees are more expensive than visits to a specialist in their consulting rooms. My colleagues and I provide a 24hour service taking calls from the midwifery staff if they are concerned about your baby, or attending in person if there is an emergency. There is no separate cost for this around the clock medical cover for your baby; it is factored into my overall fee.

Most babies won't need any further follow-up with me after discharge but all babies need a check at six weeks of age - this should be performed by your local GP. I will let you know if you need to bring your baby back to my consulting rooms to see me for a further review. If your baby does need to come back and see me again, this is associated with a separate fee (more information will be provided to you at the time of making the appointment).

If there are any concerns about your baby at any time once you go home from hospital, please don't hesitate to get in touch with me.

Please confirm the following:

I understand and consent to the care being provided to my baby by my paediatrician at the request of my obstetrician

I consent to the collection and storage of personal medical information and the distribution of this information to relevant parties

I allow the clinical information collected to be used anonymously for clinical practice improvement and research

I understand that there are fees for this paediatric service and out of pocket costs as detailed above.

I consent to electronic communication including medical results using my email address

Signature