Informed Consent Agreement

I understand the following:

 The lactation consultant is an allied health care provider and is responsible for evaluating and recommending a care path to resolve or improve breastfeeding issues. A lactation visit includes a detailed history of the mother/infant, an assessment of maternal/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, and recommendations for management to improve and/or resolve breastfeeding-related issues. All clients are provided with a written and/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 care path at some point.

I understand the following:

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. Phone contact during the time following the lactation visit is crucial and considered an extension of this visit. I understand I will be given a phone number to call to report progress or to communicate continued problems or concerns.  I understand it is my responsibility to call the lactation consultant with progress reports, questions, or concerns.

I understand the following:

Any change from my physician’s recommendations should be discussed with the physician. Health care issues of a medical nature MUST be discussed with a physician.

I understand the following:

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

I understand the following:

 I authorize 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, referring physician, referring lay breastfeeding counselor, and/or our insurance company upon request.

I understand the following:

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 the following:

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

I understand the following:

 This practice accepts only fees for service at the time of service. It is my responsibility to pursue reimbursement for lactation services from my insurance company. This practice does not bill for insurance reimbursement. This provider has partnered with The Lactation Network for some covered insurance plans. Reimbursement is not guaranteed, but filing is suggested.

I understand the following:

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