Oh, Baby! Consent for Care and Basic Information

Date of Visit-____________________

Aetna Insurance ID #  if applicable (N/A _______)_____________________________

Who is the Aetna primary subscriber?________________________________

(if not Parent/Mother, please include name and DOB of the subscriber)

_______________________________________________________________

Place of Visit- Home or office (circle one)

Parent/mothers name_________________________________________

Parent//Mothers Date of Birth____________________________

Child(s) name_________________________________________________

Child(s) Date of Birth_______________________________

Address-____________________________________________________________________

Form of payment for visit- circle-    Check     Cash      HSA     Aetna      Credit/debit card

PLEASE READ AND SIGN BELOW-

I agree to allow a certified Lactation Consultant, RN, LPN, or other provider, to provide physical breastfeeding care for me and my baby (or babies).

If this is uncomfortable for me, I will tell the staff, and work on parameters for what physical care is allowed. Any touch or exam will be fully explained and discussed prior.

I understand a Treatment Plan of Care includes me and my families’ cultural and personal beliefs, and I will share these beliefs openly and clearly with my lactation care provider.

Plans of care change, and I agree to communicate any changes in plan or desire to pursue plan of care with Oh, Baby! staff.

I understand any changes from my infant or OBGYN health care provider plan of care should be discussed with said provider. Immediate health care concerns or changes should be discussed with you or your child's Health Care Provider ASAP. Oh, Baby! Can help guide choice and troubleshoot breastfeeding issues, but emergent physical concerns require higher level care.

All documented care is protected healthcare information for Oh, Baby!, and is treated as such.

I authorize Oh, Baby! staff to release any information acquired in the evaluation and/or management of myself or my child to our Health Care Providers, referring physician, and/or insurance companies upon request. I understand Oh, Baby! Staff may contact my HCP or my child's HCP if necessary.

I understand this practice accepts fee for service at the time of service. Payment plans are accepted only with a credit card on file for structured payments. This will be laid out clearly prior to care being rendered.

If I have a participating Aetna plan, I understand Oh, Baby! will bill the visit directly to Aetna. Aetna does not cover travel fees for home visits. They might not cover the entire billed fee, or cover the infant portion of the visit.

I agree to pay any fees not covered by Aetna, or put towards deductible or patient responsibility,  to Oh, Baby! Lactation.

Signature-____________________________________________________________________

Date-___________________________