Consent for Treatment and Billing

1. I give my permission for this and future breastfeeding consultations to be performed by the Breastfeeding Center's International Board Certified Lactation Consultant(s) (IBCLC). Consultations may consist of the following: health history for you and your baby, an examination of your breasts, nipples and baby's oral anatomy, a pre- and post-feed weight to evaluate transfer of milk, discussion of calibrating supply, assessment of latch and positioning, assistance with the use of breastfeeding aids and equipment, and a care plan to help you meet your breastfeeding goals.

2. I understand that I am financially responsible for all supplies used at the time of my consultation(s), and any breastfeeding supplies left with me in my home at a home visit. My consultant will verbally confirm cost with me before use in my consult. For Office Visits I understand I will pay for these items at the end of my consult. If I have a Home Visit, my consultant will include a list of supplies used/given to use, and their associated cost, within the care plan that is emailed to me at the end of my consult. I will be billed for these items within 30 days of my consult and a receipt will be emailed to me at the email address provided within this form. 

3. I understand that the Breastfeeding Center is an in-network provider for many but not all Aetna, Blue Cross/Carefirst, and United plans, and not for any other insurance provider. I understand if I have a plan managed by Aetna, Blue Cross/Carefirst, or United, and I provide all of the necessary information in order to do so, the Breastfeeding Center will attempt to bill my consultation directly to my insurance provider; I authorize The Breastfeeding Center to do so. I understand that I am financially responsible for any portion of the cost of my consult deemed "patient responsibility" by my insurer, never to exceed the fees for service, as listed above. If I do not have a plan managed by Aetna, Blue Cross/Carefirst or United, I understand that I will pay for my consult in full, as outlined above in "fees for service" and that forms will be provided to me, at the email address given in this form, to assist me in seeking reimbursement with my insurer. 

4. By providing my credit card information here, I authorize The Breastfeeding Center to charge my card for all consultations not covered by my insurance, rentals and supplies, as well as appointments not canceled at least 24 hours in advance. The fees for service as of 1/1/20 are as follows: Prenatal Lactation Consultation (60 min) $200, Postnatal Lactation Consultation (60-75min) $200, Home Visit Travel Fee $100. I understand that Office Visits are billed at the time of service, and Home Visits are billed within 30 days of my consult. A receipt for all charges will be emailed to me, at the time of billing, to the address provided here. Any patient responsibility determined by my insurer will be invoiced after my claim is billed to my insurer, this invoice will be automatically charged 7 days after sending to the email on file, to the card provided on file, unless I contact The Breastfeeding Center by phone to change my card, delay payment, or set up a payment plan. I hereby acknowledge responsibility for this account and guarantee payment of all charges against this account. I understand that this account is my responsibility. I understand that outstanding balances over 120 days may be referred to an appropriate collection agency. 

5. I understand that my email address will be used for administrative purposes only. I authorize the Breastfeeding Center to email me my notes containing the information discussed during the consultation(s). 

6. I authorize the lactation consultant(s) to release the information gained from the consultation(s) to my OBGYN or Midwife, my baby's pediatrician, and my insurance company (to assist with claim reimbursement), and to my emergency contact, if I provide one, and if necessary. 

7. I have read and understand the Breastfeeding Center's Cancellation Policy: http://breastfeedingcenter.org/cancelation-policy

8. I have read and understand the Breastfeeding Center's Insurance FAQ: http://breastfeedingcenter.org/insurance-coverage

9.  I understand that all medical care for my baby and me is to be provided by my physician(s) and team of primary healthcare providers. I understand an IBCLC cannot provide medical diagnosis, healing, treatment, or surgery. I understand an IBCLC can and will provide comprehensive maternal, child and feeding assessments related to lactation; develop and implement an individualized feeding plan in consultation with me; provide evidence-based information regarding the use, during lactation, of medications (over-the-counter and prescription), alcohol, tobacco and street drugs, and their potential impact on milk production and child safety; provide evidence-based information regarding complementary therapies during lactation and their impact on a mother’s milk production and the effect on her child; integrate cultural, psychosocial and nutritional aspects of breastfeeding; provide support and encouragement to enable me to successfully meet my breastfeeding goals. 

10. If I choose to have an end-to-end encrypted Video-Call consult: I understand that any internet based communication is not guaranteed to be secure and agree to the risks associated with this type of communication. 

11. I am aware of and understand the Notice of Privacy Practices of Lactation Consultation (HIPAA). http://breastfeedingcenter.org/wp-content/uploads/2018/09/BCGW-HIPAA-Notice-of-Privacy-Practice.pdf 

12. Consent will remain active during the course of care, unless revoked in writing to the Breastfeeding Center of Greater Washington attn: Gina Caruso.