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CONSENT AGREEMENT to be READ, CHECK to AGREE & SIGNED before the Lactation Visit

✅ I understand the following: The lactation consultant is an allied health care provider and responsible for evaluating andrecommending a care path to resolve or improve breastfeeding issues. A lactation visit includes a detailed history of mother/infant, anassessment of maternal/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, andrecommendations for management to improve and/or resolve breastfeeding related issues. All clients are provided with a writtenand/or oral care path to improve breastfeeding concerns. The client and the lactation consultant each have responsibilities in this path.Resolution of a breastfeeding problem often takes several days or weeks and may require a change in the original recommended carepath at some point.

✅ I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care path at the timeof the visit or during the course of follow-up communications. Phone contact during the time following the lactation visit is crucialand considered an extension of this visit. I understand I will be given a phone number to call to report progress or to communicatecontinued problems or concerns. I understand it is my responsibility to call the lactation consultant with progress reports,questions or concerns.

✅ I understand any change from my physician’s recommendations should be discussed with the physician. Health care issues of amedical nature MUST be discussed with a physician.

✅ I understand a partial or follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps maybe recommended as effective management of specific situations. Only effective breastfeeding equipment will be recommended.

✅ I authorize the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or mychild to our health care providers, referring physician, referring lay breastfeeding counselor, and/or our insurance company uponrequest. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it isnecessary to consult with the physician.

✅ I have received a copy of the lactation consultant’s HIPAA Privacy Practices or understand it is available on lactation consultant’swebsite.

✅ I understand the lactation consultant is a provider on a limited number of insurance plans and will only bill my insurance if thelactation consultant is contracted as an in-network provider with my plan. All services provided for insurance plans for which thelactation consultant is NOT a provider are fee for service at time of service. It is my responsibility to pursue reimbursement forlactation services from my insurance company when the lactation consultant is not an in-network provider on my insurance plan, inwhich case, full or partial reimbursement is not guaranteed.

✅ I understand this practice accepts only fee for service at time of service. It is my responsibility to pursue reimbursement forlactation services from my insurance company. This practice does no billing for insurance reimbursement and is not a provider on anyinsurance plan. Reimbursement is not guaranteed, but filing is suggested.

✅ I give permission for information, photos and/or videos of my lactation visit to be used in lactation articles, case studies or otherstudies for professional lactation or maternal/child education.

✅ I understand that cancellations made 24 hours or less before an appointment will be subject to a cancellation fee of $50.

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