Riverside Lactation LLC's Consent form

I give my consent for the lactation consultant to work with me and my baby/s during this consultation for my breastfeeding/chestfeeding problem/concern. This consent is for in-person visits, as well as phone conversations, and any information sent/ communicated by email, mobile phone, fax, SMS text messages, and/or private social media. I understand that electronic/cellular forms of communication may not be encrypted secure. Email communications are sent from her HIPAA secure gmail account. Text messaging and social media are not HIPAA-compliant and should not be used for communicating about your care.

I understand that a lactation consultant may involve: touching my breasts and/or nipples for the purposes of assessment; inserting gloved fingers into my baby’s mouth to assess suck; observation of 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 or other methods of infant feeding. Any interns of Riverside Lactation present during appointments will engage in these exams under the supervision of Rachel Blumberg, IBCLC.

I understand that I am responsible for informing the lactation consultant of changes I feel are necessary in the care plan at the time of the visit or during the course of follow-up communications. I can contact the lactation consultant by phone/email to discuss parts of the plan that need clarification. New questions or concerns are a scheduled visit. The lactation consultant will respond to communications within 24-36 hours Monday-Friday.

**I understand Rachel Blumberg is a state mandated reporter. She is required to contact CPS if there is suspected child abuse, neglect or elderly abuse or neglect.

I give my consent for the lactation 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 breastfeeding counselor, and/or our insurance company upon request. I understand the lactation consultant may contact my physician or my child's physician if the lactation consultant feels it is necessary to consult with the physician.

I give my consent for the lactation consultant to use clinical information and any photographs obtained during our sessions for conferring with other healthcare providers and education of mothers about lactation. I won't be identified in any way, bust aspects of my situation may be described and discussed.

A consult with the lactation consultant is not a guarantee of any outcome, but is a guarantee of evidence-based information and skilled lactation support. After the initial consult, I may need 2-6 consults depending on the individual situation.

I hereby authorize and direct my insurance company to pay directly to Riverside Lactation LLC such sums as may be due for services rendered. Any funds I receive as payment for services, I agree to promptly direct to Riverside Lactation LLC. Any overages may be applied to any non-covered charges.

Appointments are billed to insurance and are subject to copays, coinsurance, and deductibles if applicable. Payment is accepted with cash, check, debit/credit cards or HSA cards. I understand payment of copays or the full amount if not using insurance is expected at the conclusion of the consultation. If my plan is subject to a deductible or any services rendered are not covered under my insurance plan, I will be billed for what was not covered by my insurance company and that payment is due UPON RECEIPT of the invoice. Online video consults and phone consults are available; this reservation fee is paid in advance via debit/credit cards or HSA cards and is not refunded if you fail to attend. Phone consultations are not currently covered by insurance. Cancellations or no shows are 50% of the appointment fee without 24 hours notice with a phone conversation (no email or text cancellations). Insurance does not cover this fee.

I understand that it is my responsibility to follow up with my insurance company on incorrectly applied payments, underpayments, and denied charges. I agree to pay the difference between contracted amounts and payments provided to Riverside Lactation LLC from my insurance company. As a courtesy Riverside Lactation LLC may make an attempt to correct my insurance company’s errors, but I understand that I am responsible to coordinate appeals with the insurance company with whom I have contracted.

I understand that I am responsible to verify my insurance eligibility and coverage. If my insurance company denies any portion of my bill, denies visits or medical necessity, applies an unexpected portion to deductible, or does not pay for another reason not here listed, the following applies: I understand that the terms of coverage conveyed to me by this office or by a representative/website from my insurance carrier do not guarantee payment or accuracy. Final payment determination is made by my insurance company upon receipt of the claim and review of documents. I agree to pay any unpaid charges.

I understand that I am fully responsible for any costs to collect my bill. Costs may include, but are not limited to collection bounced checks, agency fees, attorney’s fees, and court costs deemed necessary by Riverside Lactation LLC to collect my bill. I understand that I will be charged a $30 late fee per month for any balances due past 30 days. I additionally understand that I will be charged interest of 5% per year on any unpaid balances.

I designate Rachel Blumberg, IBCLC and Riverside Lactation LLC to the full extent permissible under the Employee Retirement Income Security Act of 1974 (ERISA) and as provided in 29 CFR 2560-503-1(b) 4 to otherwise act on my behalf to pursue claims and exercise all rights connected with my employee health care benefit plan, with respect to any health care expenses incurred as a result of the services I receive at Riverside Lactation LLC. These rights include acting on my behalf with respect to initial determinations of claims, to pursue appeals of benefit determinations under the plan, to obtain records, and to claim on my behalf such health care reimbursements.

I understand that for this lactation consultation and all follow-ups, 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). This also applies to any interns of Rachel Blumberg, IBCLC present in addition to the IBCLCs while I am undergoing IBCLC examination and treatment. I have received a copy of this providers Notice of Privacy Practices: https://www.riversidelactation.com/hipaa-privacypolicy. I understand that Riverside Lactation LLC has the right to change the Notice of Privacy Practices at any time, that a copy of any updated version will be available on the website, and that I may contact Riverside Lactation LLC at any time to request a current Notice of Privacy Practices. I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

In order for Riverside Lactation to drive to your home we will be inserting your address into Waze. The Lactation Consultant's spouse will be given your address for personal safety.

I accept that Riverside Lactation LLC send me, via email, information about lactation consulting, services, courses, and newsletter. I acknowledge I can withdraw my consent at any time by unsubscribing.

By signing below, I agree to all of the above.


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