* I understand the following: Melissa Cole, IBCLC, RLC is an allied health care provider and responsible for evaluating and recommending a care path to resolve or improve issues. A visit includes a detailed history, an assessment of anatomy if required, and recommendations for management to improve and/or resolve related issues. All clients are provided with a written and/or oral care path to improve concerns. The client and the consultant each have responsibilities in this path. Resolution of a problem often takes several days or weeks and may require a change in the original recommended care path at some point.
*I understand that I am responsible for informing the 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 your visit. You 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 consultant with progress reports, questions or concerns.
*I understand 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 a partial or follow-up visit is sometimes necessary. I understand that supplies and/or supplements may be recommended as effective management of specific situations. Only effective supplies will be recommended and the client is never obligated to purchase or use any recommended supplies. If a client chooses to utilize any equipment, supplies or nutritional supplements risks and benefits will be discussed but the client is responsible for choosing whether or not to use these items and for any associated outcomes.
*I hereby authorize the 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 counselor, and/or our insurance company upon request. I understand the consultant may contact my physician or my child’s physician if the consultant feels it is necessary to consult with the physician.
*I have received a copy of this provider’s Privacy Practices (located online http://www.lunalactation.com/wordpress/wp-content/uploads/2014/03/HIPAA-Privacy-Practices.pdf and available in office).
* I understand this practice accepts only fee for service at time of service. It is my responsibility to pursue reimbursement for services from my insurance company. This practice does no billing for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but filing is suggested.