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     36-9C-33.   Informed consent document. A certified professional midwife shall, at an initial consultation with a client, provide a copy of an informed consent document to be signed by the certified professional midwife and the client that discloses all of the following in writing:
             (1)      The name, address, telephone number, and license number of the certified professional midwife;
             (2)      The certified professional midwife's experience, qualifications, and training;
             (3)      The certified professional midwife's fees and method of billing;
             (4)      The right of a client to file a complaint with the board and the procedures for filing a complaint;
             (5)      If the certified professional midwife has malpractice liability insurance;
             (6)      A plan for consultation, referral, and transport for medical emergencies specific to each client, including identification of the closest hospital with an obstetrics department and the closest hospital with an emergency department;
             (7)      A list of antepartum, intrapartum, and postpartum conditions that would require consultation, transfer of care, or transport to a hospital;
             (8)      A statement indicating that the certified professional midwife will continue to care for a client until transfer of care has been completed including the transfer of all pertinent records including allergies, medications, and obstetric risk factors;
             (9)      The scope of care and services the certified professional midwife can provide to the client;
             (10)      A statement indicating that the client's records and any transaction with the certified professional midwife are confidential, unless required by the board for review;
             (11)      The right of a client to refuse service unless otherwise provided by law;
             (12)      The client's and certified professional midwife's signature and the date of signing; and
             (13)      A statement indicating that no other licensed health care provider or hospital or agent thereof is liable for injury resulting from an act or omission by the certified professional midwife, even if the health care provider has consulted or accepted a referral from the certified professional midwife.

Source: SL 2017, ch 172, ยง 33.

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