History Form - The Mother's Milk Company

Your Name *

First

Last

Email *

Do you have or have you ever had any of the following? (check all that apply)

Headaches
Eczema
Breast Reduction Surgery
Depression
Pregnancy Loss
Difficulty Getting Pregnant
Anxiety
Raynaud's Disease or Syndrome
Difficulty staying pregnant
Anemia
Hypothyroidism
Breast Augmentation Surgery
Injury to breasts or chest
Clotting Disorder
Pre-term Birth
Breast Cancer
Irregular periods
Family History of Breast Cancer
Eating Disorder
Allergies
Gestational Diabetes
Other Breast or Chest Surgery, Abnormality or Injury
Polysystic Ovary Syndrome
Pre-eclampsia
Mastitis
Vaginal Yeast Infection During Pregnancy
Gastrointestinal Problems
Nipple Piercing

The Mother's Milk Company Consent for Care and Treatment

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

Consent for Care and Treatment *

I have read the Mother's Milk Company Consent for Care and Treatment and give consent for care and treatment for myself and my infant.

Notice of Privacy Practices of The Mothers Milk CompanySM

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I can freely share the details of your protected health information for purposes of “treatment, payment and health care operations.” That means I can talk to you about you situation, and discuss it with your other health care providers. If you are referred to other specialists, I can send the information on to them.

The law also requires me to share your information under other, very precise situations: for example, if a subpoena has been served on me, to turn over medical records ... or a federal agency is investigating a complaint that I have not been protecting your privacy.

Any other time I share your personal health information, it has to be with your specific authorization: you have to okay it, in writing, first. For example, you may want me to send information about your consultation to the Human Resources Dept. at your office, so they can pay you back under their corporation lactation support program. When you do give me permission to turn over information about you, I CAN GIVE OUT ONLY THE MINIMUM AMOUNT OF INFORMATION NEEDED TO GET THE JOB DONE.

Under HIPAA, I can call or write you to remind you to come back for an appointment, or to tell you how you can get a product or service that might interest you and your family. You have four rights under HIPAA: (1) Access (you can ask the lactation consultant to see all the PHI she has about you); (2) Amendment (you can ask the lactation consultant to change her files to amend inaccurate PHI); (3) Disclosure Accounting (you can ask to whom the lactation consultant has given you PHI) and (4) Restriction Request (you can put limits on the lactation consultant’s use and sharing of your PHI). My duty under HIPAA is to give you this notice, so you understand I have promised to keep your private health information confidential. If I change this notice in the future, I’ll give you a new copy. I, Barbara Hardin, am the Privacy Officer for The Mother’s Milk Company. You may contact me at 773.595.5593. I will answer your questions or concerns about how I protect the privacy of your health information.

You can complain if you think the lactation consultant hasn’t protected your privacy. I am the Privacy Officer, so first you’d have to complain to me ... and I have a duty to remedy the problem. I can’t penalize you for making a complaint. If I don’t address your complaint adequately, you can go over my head to the Office of Civil Rights of the federal Health and Human Services Department, to ask that a formal investigation be made. You can get all the details from them by calling (toll free) 1- 800-368-1019, or see their website at www.hhs.gov/ocr/privacy You cant’ go to court and sue me over a HIPAA violation – but you can ask HHS to investigate.

Download Notice of Privacy Practices of The Mothers Milk CompanySM