HIPAA Privacy Policy and Consent Form
Please complete this form prior to our meeting.
Erica Charpentier, IBCLC
Breastfeeding Parent's First and Last Name *
Your answer
Today's Date *
Please Read
Notice of Privacy Practices of the Lactation Consultant
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law designed to protect your privacy whenever your health care providers (like the lactation consultant) have to discuss your case, or send information about you to different offices. I have to keep a file to record our consult – but I promise that the private, protected health information (PHI) in it will be kept confidential.
I can freely share all the details of your protected health information for purposes of “treatment, payment and health care operations.” That means I can talk to you about your situation, and discuss it with your other health care providers. If you are referred to other specialists, I can send the information on to them. I can also share information with your health insurance company if they need it.
The law also requires me to share your information under other, very precise situations: for example, if a subpoena has been served on me, to turn over medical records ... or a federal agency is investigating a complaint that I have not been protecting your privacy.
Any other time I share your personal health information, it has to be with your specific authorization: you have to okay it in writing, first. For example, you may want me to send information about your consultation to the Human Resources Dept. where you work, so they can pay you back under their workplace lactation support program. When you do give me permission to turn over information about you, I can give out only the minimum amount of information needed to get the job done.
Under HIPAA, I can call or write you to remind you to come back for an appointment, or to tell you how you can get a product or service that might interest you and your family.
You have four rights under HIPAA:
(1) Access (you can ask the lactation consultant to see all the PHI she has about you);
(2) Amendment (you can ask the lactation consultant to change her files to amend inaccurate PHI);
(3) Disclosure Accounting (you can ask to whom the lactation consultant has given your PHI) and
(4) Restriction Request (you can put limits on the lactation consultant’s use and sharing of your PHI).
My duty under to HIPAA is to give you this notice, so you understand I have promised to keep your private health information confidential. If I change this notice in the future, I’ll give you a new copy. I am the Privacy Officer for my one-person company. My name and phone no. are: Erica Charpentier, 914-861-5228. I will answer your questions or concerns about how I protect the privacy of your health information. You can complain if you think your privacy hasn’t been protected by the lactation consultant. I am the Privacy Officer, so first you’d have to complain to me ... and I have a duty to try to patch things up. I can’t penalize you for making a complaint. If I don’t address your complaint adequately, you can go over my head to the Office of Civil Rights of the federal Health and Human Services Dept., to ask that a formal investigation be made. You can get all the details from them by learning how to file a complaint at http://www.hhs.gov/ocr/privacy/hipaa/complaints/. You can’t go to court and sue me over a HIPAA violation -- but you can ask HHS to investigate.

Consent for Lactation Consultation
I give my consent for the lactation consultant to work with me and my baby during this consultation for my breastfeeding problem/concern. This consent is for face-to-face visits and all follow-up contacts; it includes phone conversations, and information sent via the Internet, fax or regular mail.
I understand that a lactation consultation may involve:
• touching my breasts and/or nipples for the purposes of assessment;
• inserting gloved fingers into my baby’s mouth to assess suck and oral cavity;
• observation of a breastfeed, and suggestions to enhance latch or position;
• demonstration of the use of equipment or supplies that may be recommended, and
• demonstration of techniques designed to improve breastfeeding.
I give my consent for the lactation consultant to contact my baby’s and my primary health care provider with a report of our consultation, as the ethics of her profession require, and to consult with them in any way she deems appropriate. I agree that she may discuss my case and forward my contact information to a breastfeeding support group counselor.
I give my consent for the lactation consultant to release pertinent information to my insurance company, as necessary.
I give my consent for the lactation consultant to use clinical information obtained during our sessions for education of other health care providers and mothers about lactation. My baby and I won’t be identified in any way, but aspects of our situation might be described and discussed.
I give permission for photographs and recordings to be made, of both me and my baby, for charting and clinical education purposes. If the photographs are shared in a clinical or educational context, identifying features or information will not be shown.
I may choose to communicate with the lactation consultant by email and/or cellular text. I understand that these forms of communication may contain my protected health information, and that these electronic means of communication are not encrypted/secure.
I understand that total payment is expected at the conclusion of the consultation. I will receive paperwork to submit to my insurance company for consideration of reimbursement.
I understand that for this lactation consultation and all follow-up, the lactation consultant will protect the privacy of my personal health information as required by the Code of Professional Conduct of the International Board of Lactation Consultant Examiners, the IBLCE Scope of Practice for IBCLCs, the Standards of Practice of the International Lactation Consultant Association, and the Health Insurance Portability and Accountability Act of 1996
© ECB JD IBCLC FILCA, December 2011, adapted with permission March 2012
See below: *
Never submit passwords through Google Forms.
This form was created inside of Erica Charpentier, IBCLC. Report Abuse