I give my consent for Dalaney S. Young, BS MCH, IBCLC, owner of newday lactation services LLC to enter my home to evaluate the breastfeeding dyad and develop a care plan for my and my baby during the visit. This consent includes the home visit (current and future), as well as any electronic means of communication and/or information shared via phone, cell, text, e-mail, fax as well as regular mail. I do understand that not all forms of electronic or cell phone forms of communication may not be encrypted or secure.
I understand that a lactation visit requires detailed and accurate information from the family regarding the birth and health histories of both mother and baby as requested in newday lactation services Intake Form. I understand that a physical exam will be performed on both the mother and baby.
A lactation visit from newday lactation sefvices may include one or more of the following:
* The touching of breasts and/or nipples for purposes of assessement
* The insertion of a gloved finger to assess the infant's suck
* Observations of an actual feeding at the breasts and the lactation consultant may have suggestions
to implement on approval of the mother. Demonstrations of techniques may be shown.
* Demonstration of any supplies and/or equipment that may be recommended
I understand that payment is to be completed at the end of the home visit. Newday Lactation Services will give mother an invoice for purposes of insurance reimbursement. I understand that Newday Lactation Services cannot guarantee reimbursement from your health insurance provider. No refunds are given by Newday Lactation Services for services already rendered.
As an in-network provider with Aetna, we will file for your insurance to reimburse us directly. Your insurance policy is a contract between you and Aetna, and they will make the final determination of your benefits. You will be responsible for any patient responsibility determined by Aetna.
I give consent for my lactation consultant to release any information obtained during the visit and during any previous and subsequent communication to my health care provider and/or the baby's health care provider. I understand that newday lactation services may contact my physician or infant's physician if there is a need determined by the lactation consultant.
I understand that many breastfeeding issues are not resolved immediately. Newday Lactation Services will work with you to reach your goal, but follow up consultations may be necessary with the mother's approval at an additional fee.
I give permission for the lactation consultant to use clinical information about my case when conferring with other health care providers or for the education of other mothers about breastfeeding. I will not be identified in any way, but my situation may be discussed and/or described.
Privacy Practices for newday lactation services are available on our website www.newdaylactation.com and a copy is available upon request.
I have read, understand and agree to all of the above.