CONSENT FOR CARE

I give my consent for the Board Certified Lactation Consultant, Jessica Wimer of Born and Fed, to evaluate and recommend a care plan for me and my baby during this consultation for my breastfeeding concerns. A lactation visit 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 conversations, texts, information sent by-mail, fax or regular mail. I understand that a lactation consultation may involve:

I give my consent for the Board Certified Lactation Consultant, Jessica Wimer of Born and Fed, to evaluate and recommend a care plan for me and my baby during this consultation for my breastfeeding concerns. A lactation visit 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 conversations, texts, information sent by-mail, fax or regular mail. I understand that a lactation consultation may involve:

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

  1. inserting a finger or pacifier into my baby’s mouth to assess suck;
  2. observation of a breastfeed, and suggestions to enhance latch or position;
  3. demonstration of the use of equipment or supplies that may be recommended,
  4. 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.

Unless you are presenting me with an In-Network insurance card (Aetna, Independence Blue Cross) 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 In-Network Insured Patients Only: Plans with the women’s preventive services benefit cover 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 my insurer to you, the Provider, if possible. I understand and consent to provide credit card information at the time of booking to be used in the event of:

  1. Late cancelation charges
  2. Any cost sharing benefits that are not covered under your plan or any portion of your bill that is not paid by insurance.

You will be notified of any charges before they incur and give the option to pay by cash or check. Cash pay services will require payment up front.

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). I understand a copy of the Notice of Privacy Practices was provided via e-mail and can be reviewed here.

I give my consent for the Board Certified Lactation Consultant, Jessica Wimer of Born and Fed, to evaluate and recommend a care plan for me and my baby during this consultation for my breastfeeding concerns. A lactation visit 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 conversations, texts, information sent by-mail, fax or regular mail. 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. Unless you are presenting me with an In-Network insurance card (Aetna, Independence Blue Cross) 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 In-Network Insured Patients Only: Plans with the women’s preventive services benefit cover 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. Ido authorize direct payment from my insurer to you, the Provider, if possible.I understand that for this lactation consultation and all follow-up, the lactation consultant will protect theprivacy of my personal health information as required by the Code of Ethics of the International Board ofLactation Consultant Examiners, the Standards of Practice of the International Lactation ConsultantAssociation, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand a copy of the Notice of Privacy Practices is available.

Illness Policy

UPDATED 03/16/2020

I will continue to operate so that I can continue to meet the needs of the families I serve, as long as it is safe to do so. With that in mind, Born and Fed is implementing some changes in operations as a precaution in response to the onset of COVID-19. I am asking for your help and cooperation with these precautions.

In light of recent events worldwide, I have updated some policies for illness. I want all of us to be safe. If meeting in person is not an option, I do offer virtual (phone or video) telehealth consultations.

Clients should NOT schedule an appointment if YOU or ANYONE in your family or home (client, infant, sibling(s), partners, caregivers, guardian, or visitors) have a fever or are experiencing respiratory illness symptoms such as frequent coughing or sneezing, and a runny nose.

Please let me know in a timely manner if you or anyone in your family is symptomatic for ANY illness.
If you or anyone in your home is sick with the flu, fever, vomiting, or diarrhea DURING the visit, the visit will be canceled and your credit card will be charged a $75 fee.

If you or anyone in your home has symptoms of illness, please disclose this to me at your earliest convenience BEFORE the appointment so we can create a plan to keep us all safe and illness-free. No cancellation fee will be charged if you communicate illness in a timely manner and we choose to cancel or reschedule.

In case of my own illness or family emergency, I will communicate with you in a timely manner and will make every effort to reschedule you or refer you to another IBCLC, and no cancellation fee will be charged to you.

The Born and Fed cannot hold or save appointments for individuals who choose to cancel as a precautionary measure.
I would request that if at all possible, no unnecessary visitors be allowed at the consultation.
As always, I will be washing my hands as often as necessary during the consult, sanitizing my equipment, and removing my shoes in your home. Upon request, I can wear a N95 mask during our visit. The Born and Fed cannot guarantee that I, Jessica Wimer, have not been exposed to the coronavirus or any other illness.

Other measures to protect health:
Any equipment used will be sanitized multiple times a day and after each use.

What you can do to help:

I suggest visiting the CDC AND www.kycovid19.ky.gov for reliable guidance and factual information regarding COVID-19.
Hotline to call on when to seek care 1-800-722-5725. Please do not flood the healthcare system if it is not necessary.


*Cancellations within 24 hours without communication or office visit no-shows will be charged 50% of the consult rate.
I will continue to closely monitor the situation and do all I can to protect your family and mine. We can all help to decrease the spread of illness with good hand washing and hygiene. As the situation changes, I will adjust recommendations and practices accordingly and will notify you via email. If you have any concerns or comments, please don’t hesitate to contact me via email, jwimer@bornandfed.com


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