Consent for Care and Treatment
I hereby give my written consent for Barbara Hardin, RN, IBCLC or other Mother’s Milk Company IBCLC to work with my baby and myself during this tele-consultation or in-home consultation and for subsequent consultations for my breastfeeding problems/concerns. Visual observation of infant feeding at the breast, including visualization of mother’s breasts and infant’s oral cavity may occur. No photographing, recording or taping (audio or video) will occur during a tele-consultation. A HIPAA compliant telehealth platform will be used when available. During in-home consultation I understand that this consultation may involve observation of a breastfeed, touching my breasts and/or nipples for the purposes of assessment, performing an oral digital examination on my baby in order to assess the suck, and demonstration of use of equipment and techniques that may be necessary to improve breastfeeding.
I give my written consent for the IBCLC to send any and all pertinent information to my infant’s and my primary health care providers, as well as any other Allied Health Professional that may be involved in my and my infant’s care and to consult with them in any way she deems appropriate including electronic transmission of such information.
I give my written consent for the IBCLC to release pertinent information to my insurance company, or other entity that may be involved in the processing of my insurance claim, as necessary.
I authorize the Mother’s Milk Company to receive payment for services from my insurance company if the Mother’s Milk Company bills my insurance provider for services rendered. I understand that if I submit the claim for the Mother’s Milk Company’s services to my insurance company I will be the recipient of the payment from said insurance company.
I give my written consent for the IBCLC to use clinical information obtained during these sessions for education of other health care providers or mothers about lactation. Information used in this way will not contain my name or my baby’s name but aspects of my situation might be described or discussed.
I understand that total payment is expected at the conclusion of the consultation unless prior arrangements have been made. I further understand that I will receive appropriate forms that can be submitted to my insurance company for reimbursement.
I understand that the Mother’s Milk Company will protect the privacy of my personal health information as required by the Code of Professional Conduct of the International Board of Lactation Consultant Examiners (IBLCE), the International Lactation Consultant Association (ILCA) Standards of Practice and in compliance with the Federal Health Insurance Portability and Accountability Act of 1996(HIPAA).
I give my written consent to receive emails or phone calls from the Mother’s Milk Company from time to time regarding information, a product, service or survey that may interest me.
I acknowledge that I have had full opportunity to discuss and understand information and treatment options provided by the Lactation Consultant. I understand that I have the right to refuse any or all specific techniques or treatments suggested, and any or all equipment provided or recommended to assist or remedy breastfeeding problems.
I understand The Mother’s Milk Company does not have a HIPAA compliant text messaging platform and that messaging may not protect the privacy of my health information.
Download The Mother's Milk Company Consent for Care and Treatment