Release of Liability and Consent Form A lactation consultation, whether in person or virtual, usually includes visual and physical assessment of the breastfeeding parent’s breasts, visual and physical assessment of the infant’s mouth, observation of the breastfeeding parent and infant nursing, analysis of data relating to the breastfeeding situation, demonstration of techniques for improving breastfeeding, and sometimes the use of breastfeeding equipment. I also give permission for my baby to receive craniosacral therapy as needed. I understand that I have the right to refuse any or all specific techniques suggested, equipment to assist or remedy breastfeeding problems, and/or all recommended actions.I give permission for Petra Tupy, RN, IBCLC to do all of the above. I understand that all medical care is to be provided only by a physician(s). I give my permission for information about this and all additional consultations to be sent to my attending physician(s) / health care provider(s). I understand the Lactation Consultant will make recommendations toward helping me reach my breastfeeding goals. I understand no outcome can be guaranteed. It is my responsibility to evaluate the effectiveness and sustainability of this care plan, and to contact my Lactation Consultant for advice, adjustments, and follow-up as necessary. I understand that my session includes 14 days of follow-up support with Petra Tupy. After that time, for additional questions or requests for additional lactation support, I will need to request a follow-up consultation. I understand that I have the right to refuse any or all specific techniques suggested, equipment to assist or remedy breastfeeding problems, and/or all recommended actions. I acknowledge that Petra Tupy has provided their HIPAA policy and HIPAA-compliant means of communication. If I choose not to use the HIPAA-compliant form of communication that Petra Tupy has provided, I understand that although email or text are not inherently secure means of communication the Lactation Consultant will take all reasonable precautions to protect my privacy. 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 (HIPPA). I understand that a student lactation consultant may be present to observe my consultation. I have received a copy of this provider’s Notice of Privacy Practices. I understand that it is my choice to have someone else present during the visit and that anyone who sits in on the visit will have access to my healthcare information and my confidentiality may not be guaranteed. I acknowledge that Petra Tupy is not responsible for any breach of confidentiality made by anyone I invite to be present during a visit, or anyone added by me as a third party to text or email. I give my permission for information from this consultation/visit to be used to further the knowledge of breastfeeding and / or educational purposes. I understand that my identity and the identity of my child(ren) will be kept private. I understand that no specific names will be publicly used. I understand that this consultation is not being recorded, and that no pictures or videos will be taken or shared from this consultation without me providing prior written consent. I have read and reviewed Petra Tupy’s payment policies and acknowledge that I am responsible for all charges associated with this visit. I give my permission for information to be released to my insurance company to assist in the evaluation of a claim. I give my permission for Midwest Lactation LLC to bill my insurance and collect payment if I have not paid cash at the time of service. If I have not met my deductible, or my insurance does not pay, I agree to pay Midwest Lactation LLC the balance of the consult. I have been given the cash rates for consultations. I agree with the use of digital signatures in my interactions with Petra Tupy / Midwest Lactation LLC. . Any signature of mine that is provided digitally will be assumed to carry all the weight and authority of an original manual signature.