Consent Form

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Breastfeeding parent name
First Name
Last Name
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Baby's name
First Name
Last Name
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Baby's date of birth
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Breastfeeding challenges, goals or anything related you would like to share
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Email
example@example.com
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Phone Number
Please enter a valid phone number.
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Release of Liability and Consent Form A lactation consultation, whether in person or virtual, usually includes visual and physical assessment of the breastfeeding parent’s breasts, visual and physical assessment of the infant’s mouth, observation of the breastfeeding parent and infant nursing, analysis of data relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, and sometimes the use of breastfeeding equipment. I give permission for Petra Saidi, RN, IBCLC to do all of the above. I understand that all medical care is to be provided only by a physician(s). I give my permission for information about this and all additional consultations to be sent to my attending physician(s) / health care provider(s). I understand the Lactation Consultant will make recommendations toward helping me reach my breastfeeding goals. I understand no outcome can be guaranteed. It is my responsibility to evaluate the effectiveness and sustainability of this care plan, and to contact my Lactation Consultant for advice, adjustments, and follow-up as necessary. I understand that I have the right to refuse any or all specific techniques suggested, equipment to assist or remedy breastfeeding problems, and/or all recommended actions. I acknowledge that Petra Saidi has provided their HIPAA policy and HIPAA-compliant means of communication. If I choose not to use the HIPAA-compliant form of communication that Petra Saidi has provided, I understand that although email or text are not inherently secure means of communication the Lactation Consultant will take all reasonable precautions to protect my privacy. I understand that during support group confidentiality can't be guaranteed. I acknowledge that Petra Saidi is not responsible for any breach of confidentiality made by anyone I invite to be present during a visit, or anyone added by me as a third party to text or email. I give my permission for information from this consultation/visit to be used to further the knowledge of breastfeeding and / or educational purposes. I understand that my identity and the identity of my child(ren) will be kept private. I understand that no specific names will be publicly used. I understand that this consultation is not being recorded, and that no pictures or videos will be taken or shared from this consultation without me providing prior written consent. I have read and reviewed Petra Saidi’s payment policies and acknowledge that I am responsible for all charges associated with this visit. I give my permission for information to be released to my insurance company to assist in the evaluation of a claim. I give my permission for Midwest Lactation Services LLC to bill my insurance and collect payment if I have not paid cash at the time of service. If I have not met my deductible, or my insurance does not pay, I agree to pay Midwest Lactation Services LLC the balance of the consult. I have been given the cash rates for consultations. I agree with the use of digital signatures in my interactions with Petra Saidi / Midwest Lactation Services LLC. . Any signature of mine that is provided digitally will be assumed to carry all the weight and authority of an original manual signature. By submitting your name below, you agree to the terms provided above. PRINT NAME
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PLEASE TYPE YOUR NAME IN BOX ACKNOWLEDGING THE HIPPA PRIVACY NOTICE* This field is required.Background The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights. How the Rule Works General Rule. The Privacy Rule provides that an individual has a right to adequate notice of how a covered entity may use and disclose protected health information about the individual, as well as his or her rights and the covered entity’s obligations with respect to that information. Most covered entities must develop and provide individuals with this notice of their privacy practices. The Privacy Rule does not require the following covered entities to develop a notice: Health care clearinghouses, if the only protected health information they create or receive is as a business associate of another covered entity. See 45 CFR 164.500(b)(1). A correctional institution that is a covered entity (e.g., that has a covered health care provider component). A group health plan that provides benefits only through one or more contracts of insurance with health insurance issuers or HMOs, and that does not create or receive protected health information other than summary health information or enrollment or disenrollment information. See 45 CFR 164.520(a). Content of the Notice. Covered entities are required to provide a notice in plain language that describes: How the covered entity may use and disclose protected health information about an individual. The individual’s rights with respect to the information and how the individual may exercise these rights, including how the individual may complain to the covered entity. The covered entity’s legal duties with respect to the information, including a statement that the covered entity is required by law to maintain the privacy of protected health information. Whom individuals can contact for further information about the covered entity’s privacy policies. The notice must include an effective date. See 45 CFR 164.520(b) for the specific requirements for developing the content of the notice. A covered entity is required to promptly revise and distribute its notice whenever it makes material changes to any of its privacy practices. See 45 CFR 164.520(b)(3), 164.520(c)(1)(i)(C) for health plans, and 164.520(c)(2)(iv) for covered health care providers with direct treatment relationships with individuals. Providing the Notice. A covered entity must make its notice available to any person who asks for it. A covered entity must prominently post and make available its notice on any web site it maintains that provides information about its customer services or benefits. Health Plans must also: Provide the notice to individuals then covered by the plan no later than April 14, 2003 (April 14, 2004, for small health plans) and to new enrollees at the time of enrollment. Provide a revised notice to individuals then covered by the plan within 60 days of a material revision. Notify individuals then covered by the plan of the availability of and how to obtain the notice at least once every three years. Covered Direct Treatment Providers must also: Provide the notice to the individual no later than the date of first service delivery (after the April 14, 2003 compliance date of the Privacy Rule) and, except in an emergency treatment situation, make a good faith effort to obtain the individual’s written acknowledgment of receipt of the notice. If an acknowledgment cannot be obtained, the provider must document his or her efforts to obtain the acknowledgment and the reason why it was not obtained. When first service delivery to an individual is provided over the Internet, through e-mail, or otherwise electronically, the provider must send an electronic notice automatically and contemporaneously in response to the individual’s first request for service. The provider must make a good faith effort to obtain a return receipt or other transmission from the individual in response to receiving the notice. In an emergency treatment situation, provide the notice as soon as it is reasonably practicable to do so after the emergency situation has ended. In these situations, providers are not required to make a good faith effort to obtain a written acknowledgment from individuals. Make the latest notice (i.e., the one that reflects any changes in privacy policies) available at the provider’s office or facility for individuals to request to take with them, and post it in a clear and prominent location at the facility. A covered entity may e-mail the notice to an individual if the individual agrees to receive an electronic notice. See 45 CFR 164.520(c) for the specific requirements for providing the notice. Organizational Options. Any covered entity, including a hybrid entity or an affiliated covered entity, may choose to develop more than one notice, such as when an entity performs different types of covered functions (i.e., the functions that make it a health plan, a health care provider, or a health care clearinghouse) and there are variations in its privacy practices among these covered functions. Covered entities are encouraged to provide individuals with the most specific notice possible. Covered entities that participate in an organized health care arrangement may choose to produce a single, joint notice if certain requirements are met. For example, the joint notice must describe the covered entities and the service delivery sites to which it applies. If any one of the participating covered entities provides the joint notice to an individual, the notice distribution requirement with respect to that individual is met for all of the covered entities. See 45 CFR 164.520(d).
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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