I understand that there were will a $25 fee for the convenience of out of area home consult for any consult that is 15 miles or more each way. This fee is NOT REIMBURSABLE by insurance (this is to cover the cost of blocking out more time due to the extra driving)
BreastfeedingHelper PC 267-879-5000 Gail Dittes RNC IBCLC
Consent for Lactation Consultation Services
I give my consent to Gail Dittes RNC IBCLC (hereafter referred to as LC) to work with me and my infant during this consultation. I understand that this may include: touching my breasts or nipples, and inserting gloved fingers into my baby’s mouth for the purpose of assessment. I understand that this will include observation of a breastfeed, and suggestions to enhance latch or position, as well demonstration of the use of equipment or supplies that may be useful.
I understand that follow–up communication is crucial and considered an extension of the consult. I understand that it is my responsibility to call, text, or email the LC with progress reports, questions or concerns. I understand that text messages and emails are not private. If I choose to communicate via text or email, I am doing so with this understanding.
I consent to communication via text message ______________ via email _____________
I authorize the LC to release the information gained from the consultation to my primary care physician(s), health care provider, and insurance company if requested (to assist with claim reimbursement). I authorize the LC to discuss my case (without names or identifying data) with other International Board Certified Lactation Consultants for the purpose of education and understanding.
Optional: During the consultation I would like my husband or support person to photograph this session for my own personal use. I understand that these photos or videos are NOT to be sold or released on the Internet. The lactation consultant agrees to be photographed or videoed for my own teaching purposes only. The LC does not agree to have photos or videos that include her shared in any way including the internet.
I understand that all medical care for my baby and me is to be provided by our physician(s) and health care providers. I understand that names of specialists given to me by the LC are for information only. It is my decision to see or not see any specialist whose name was supplied to me by the LC. The LC does NOT make referrals.
I understand that the LC 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. (HIPAA) I understand and agree that the information in this file will be kept until the infant has reached the age of majority (21) plus 7 years, per requirements in the state of PA. My signature below acknowledges my understanding of all conditions and confirms that I have received a copy of the Privacy Policies under HIPAA.
I accept payment responsibility for the breastfeeding consultation, regardless of insurance or other third party involvement. I will pay the undersigned consultant in cash, or check, or authorize the undersigned consultant to charge my credit card or paypal for services rendered, on the date of consult. (or upon receiving a bill after insurance claims have been completed if they are denied or if copayment is required) The fee for counseling service is as follows: $125.00 first hour. I understand that I am responsible for co-pays as determined by my insurance plan. Insurance plans typically cover one hour of service without co-pay or deductible, often cover longer than one hour. I will call to ask for costs beyond 1 hour.
Client's Signature _______________________________________________________________________________date __________________________________
Lactation Consultant’s Signature ___________________________________________________________date _________________________________