COPY OF CONSENT
The following is a copy of the consent form which would be signed at the time of booking. This is for your review as needed.
I give my consent for the lactation consultant to work with me and my baby during this consultation for my breastfeeding problem/concern. This consent is for visits, phone conversations, and information sent by e-mail, fax or text, and includes appropriate follow-up contacts. I understand that using the patient portal through ChARM EHR is the safest way for me to communicate with Julie Matheney directly. If I choose to send anything to Julie Matheney via email, text, or social media, I understand that they cannot guarantee that my HIPAA privachttps://secure.acuityscheduling.com/forms.php?action=edit&id=1351675#y rights are protected for that communication.
I understand that a lactation consultation may involve:
Touching my breasts/chest and/or nipples for the purposes of assessment; Inserting gloved fingers into my baby's mouth to assess suck and oral anatomy; Observation of a breastfeeding, and suggestions to enhance latch or position which may involve touching and moving my baby at my breast; Demonstration of the use of equipment or supplies that may be recommended, and demonstration of techniques designed to improve breastfeeding.
I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care path at the time of the visit or during the course of follow-up communications. I understand that breastfeeding is not static and changes daily and weekly. I understand another consultation may be necessary to help me resolve my current issues. Additional consultations may be required as my baby grows, develops and ages and as breastfeeding changes. I understand that lactation treatments are individualized and constantly changing. I understand that in between in person appointments Julie Matheney is happy to answer short questions that clarify treatment plan instructions. However, sending questions via the patient portal, email, or text is not a substitute for an in person consultation. Your ChARM patient portal (or email/text) questions should be no more than 3-5 lines long and pertain to your current treatment plan. If these questions are too complex to answer in more than 3-5 lines, a phone, video, or in person consultation may be warranted . These calls or consultations will be billed at the regular office rate ($75phone, $150 video, or $200 in office follow or $295 in home).
Phone / e-mail / text contact during the time following the lactation visit is crucial and considered an extension of your visit. You will be given an email address and phone number to report progress or to communicate continued problems or concerns. The lactation consultant will initiate these follow up conversations for up to one week. I understand it is my responsibility to advise the lactation consultant with progress reports, questions or concerns. After one week, I understand that it is my responsibility to contact the lactation consultant if further needs or concerns arise.
I give my consent for the lactation consultant to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, midwives, referring physician, referring lay breastfeeding counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child’s physician if the lactation consultant feels it is necessary to consult with the physician. I understand I have the right to request a restriction as o how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. Julie Matheney is not required to agree to the restricts that I may request. However if she agrees to the restrictions, the restriction is binding. I have the right to revoke the restriction or this consent, in writing, at any time. Julie Matheney has the right to change these privy policies as described above. I may request a copy of the revised notice of privacy at any time by calling Julie Matheney and asking for a copy to be sent by mail or at the next scheduled appointment.
I give my consent for the lactation consultant to use clinical information obtained during our sessions for education of other health care providers and mothers about lactation. I will not be identified in any way, but aspects of my situation may be described and discussed. I give my consent for photographs and videos to be taken and made during our appointment for educational and marketing purposes including The LA Lactation Lady website, social media, and educational presentations and classes. I will not be compensated financially for images or videos taken of me and my baby. The lactation consultant will ask for permission to post any pictures or videos and I reserve the right to refuse those images or videos be used or posted.
I understand our agreed upon payment is expected in full prior to the appointment time of the consultation. I understand that I can be given a superbill upon request as a receipt of payment for my consultation and I may independently submit that superbill to my insurance company for possible reimbursement. I understand that every insurance plan is different and that I may or may not be reimbursed under my particular plan. I understand that I am responsible for contacting and negotiating with my own insurance company for reimbursement for my consultation. I understand if I need to cancel my appointment, as long as I notify the lactation consultant at least 12 hours prior to the appointment I can either be granted a full refund or reschedule to a different time. If I do not notify the lactation consultant of cancelling the appointment at least 12 hours prior to the appointment or I do not show up to the appointment, no refund will be given and I will need to completely reschedule my appointment, paying in full for another appointment. My appointment is considered "no show" if I do not arrive or communicate with Julie Matheney and LA Lactation, LLC within 15 minutes of my scheduled appointment start time. If I arrive or call within 15 minutes of the scheduled appointment start time, I may keep my scheduled appointment time, but the end time will remain as scheduled and no additional time will be credited to me.
I understand that for this lactation consultation and all follow-up, the lactation consultant will protect the privacy of my personal health information as required by the Code of Ethics of the International Board of Lactation Consultant Examiners, the Standards of Practice of the International Lactation Consultant Association, and the Health Insurance Portability and Accountability Act of 1996 (HIPPA). Should there be a breech in my confidential information, my lactation consultant will notify me according to state and national laws.
I have received a copy of this provider’s Notice of Privacy Practices.