Consent Form
Consent for Lactation Consultation

I give my consent for the Board Certified Lactation Consultant, Linda Muller, to evaluate and recommend a care plan for me and my baby during this consultation for my breastfeeding concerns. A lactation visit may be in person or virtual and includes a detailed history and /or exam of mother and infant, assessment of anatomy and effectiveness of feeding. This consent is for today’s visit and future visits; phone or video conversations, texts, information sent by-mail, fax or regular mail. I understand that text messages and emails are not private or encrypted. If I choose to communicate via text or email, I am doing so with this understanding and with my consent.

I understand that a lactation consultation may involve:

1. touching my breasts and/or nipples for the purposes of assessment;

2. inserting a finger or pacifier into my baby's mouth to assess suck;

3. observation of a breastfeed, and suggestions to enhance latch or position;

4. demonstration of the use of equipment or supplies that may be recommended,

5. demonstration of techniques designed to improve breastfeeding.

I give my consent to release any information acquired in this evaluation and consultation to my baby's and my primary health care provider, referring physicians, referring lay counselors and/or insurance company.

I give my consent for the lactation consultant to use clinical information obtained during our sessions for educational purposes. You will not be identified in any way, but aspects of my situation may be described and discussed.

With the exception of Insurance subscribers, I understand that total payment for this consultation is expected at the conclusion of this visit. I understand I will receive paperwork to submit to my insurance company for consideration of reimbursement. I give my consent for the lactation consultant to release pertinent information to my insurance company, as necessary.

For Insurance Patients Only: Insurance plans with the women’s preventive services benefit cover up to six visits with a lactation consultant. Some plans are not subject to the women’s preventive breastfeeding services requirements under the Affordable Care Act (also known as the Health Care Reform Law) which includes plans that are “grandfathered” or otherwise exempt. These plans may not include all of these benefits or there may be different member cost-sharing on certain benefits. Employers with “grandfathered” plans may choose not to cover some of these preventive services or to include cost share such as a deductible, copay or coinsurance and you can contact your HR department for additional information. I understand any portion of my bill that is not paid by the insurance for any reason is then my responsibility. I do authorize direct payment from Insurance to Linda Muller, RN, BSN, CSN, IBCLC.

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 Ethics of the International Board of Lactation Consultant Examiners, the Standards of Practice of the International Lactation Consultant Association, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
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I have read and agree with these terms and give consent for the lactation consultation. *
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