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MotherBorn Lactation Services
Dana L. Ehman BA, IBCLC, RLC
www.motherborn.com
dana@motherborn.com
610-299-1038
 

Dana L. Ehman of MotherBorn as provided a link for you to review the Notice of Privacy Practices before the visit.  If you have any questions or objections about this consent, please a call 610-299-1038 before your scheduled appointment.

I give my consent for the Board Certified Lactation Consultant, Dana L. Ehman, to provide prental education and planning for my upcoming birth and breastfeeding relationship.  A lactation visit includes a detailed history and /or exam of mother, assessment of anatomy if needed. This consent is for today’s visit and future visits; phone conversations, texts, information sent by-mail, fax or regular mail.  I understand that email, text, and fax may not be encrypted and may request that no communication be sent through these electronic services.

I understand that a lactation consultation may involve:

1  breast examination (if needed)

2  touching my breasts and/or nipples for the purposes of assessment

3  demonstration of the use of equipment or supplies that may be recommended

4  demonstration of techniques for breastfeeding/latching

I give my consent to release any information acquired in this evaluation and consultation to 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 Aetna and local Indepedence Blue Cross 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 Aetna Clients Only: Aetna 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).  This 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, co-pay or coinsurance.  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 authorize direct payment from Aetna to Dana L. Ehman, IBCLC for all lactation visits.

For Independence Blue Cross Clients: Dana L. Ehman has contracted with local Indepedence Blue Cross Plans (IBX) including Keystone Health Plan East and other local plans.  IBX may be covering unlimited visits.  Dana L. Ehman may submit claims for out-of-state Blue Cross plans with the understanding that if these claims are denied because of not being an in-network provider with said plans, client will be billed for the consultation in full.  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).  This 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, co-pay or coinsurance.  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 authorize direct payment from IBX/Keystone Plans to Dana L. Ehman, IBCLC for all lactation visits. 

I understand that for this prenatal 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 (HIP AA).  I have been given access to review a copy of the Notice of Privacy Practices of Dana L. Ehman, IBCLC.

Dana L. Ehman BA, IBCLC, RLC www.motherborn.com dana@motherborn.com 610-299-1038

I have read and agree with these terms and give consent for the lactation consultation. *
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