Consent for Treatment
I am requesting an evaluation with Hannah Walsh, MS CCC-SLP, CLC (“therapist”) for myself and my infant(s).  This evaluation will include but not be limited to a visual examination and manual palpation of my breasts as well as an observation of a feeding or pumping session.

I, the undersigned, do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for Hannah Walsh, MS CCC-SLP, CLC to administer speech-language and lactation therapy treatments to the Minor.
I understand that my physician or midwife is our primary health care provider and that he/she is responsible for the overall care of my infant(s). A copy of the recommendations can be mailed or faxed to my physician/midwife for his/her information upon request.

Client Responsibility
I will provide Hannah Walsh, MS CCC-SLP, CLC with the names and contact information for other relevant healthcare providers for me and my baby, and Hannah Walsh, MS CCC-SLP, CLC may communicate with them. It is my responsibility to provide accurate information and to keep it updated.

I understand that Hannah Walsh, MS CCC-SLP, CLC, as a Speech-Language Pathologist and Certified Lactation Counselor, is an allied health care provider and is responsible for evaluating and recommending a care plan to resolve or improve breastfeeding issues. A breastfeeding evaluation includes a detailed history of parent/infant, an assessment of maternal/infant anatomy, observation of a feeding for evaluation of technique and effectiveness of feeding, and recommendations for management to improve and/or resolve breastfeeding related issues. All clients are provided with a written and/or verbal care plan to improve breastfeeding concerns. The client and the speech-language pathologist/certified lactation counselor each have responsibilities in this plan. I understand resolution of a breastfeeding problem often takes several days or weeks and may require a change in the original recommended care plan at some point.
I understand any instructions or recommendations given may be discussed with my or my child’s health care providers.

I understand that I am responsible for informing the Hannah Walsh, MS CCC-SLP, CLC of changes I feel are necessary in the care plan at the time of the visit or during the course of follow-up communication. Phone contact after the lactation visit is important and considered an extension of the visit. I understand it is my responsibility to call the speech-language pathologist, certified lactation counselor with progress reports, questions or concerns.

Confidentiality
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 have provided written notice to Hannah Walsh, MS CCC-SLP, CLC of any person(s) I wish to have present during the visit communication.
If I have requested an in-home appointment, I understand that GPS will be used to navigate to my home.

Release of Information
I give Hannah Walsh, MS CCC-SLP, CLC my consent to use or disclose my and/or my child’s protected health information to carry out my treatment. This includes sharing information with and between the health care providers such as physicians, midwife, therapists, etc.

I also authorize Hannah Walsh, MS CCC-SLP, CLC to release information about treatment for myself or my child to my insurance company.

I understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed. I further understand that information for any other purpose may not be released to anyone without my specific authorization. I may, in writing, revoke this consent at any time, but it will not have any effect on actions taken prior to my revoking the consent.

Administrative Policies
Financial Responsibility
Hannah Walsh, MS CCC-SLP, CLC only accepts fees at the time of each service. Acceptable forms of payment include: cash, check, square
All fees are subject to change by therapist at any time. Travel fees may apply for home visits outside of the Portland metro area.

Insurance Information
Hannah Walsh, MS CCC-SLP, CLC does not bill insurance companies directly. Obtaining reimbursement from the insurance company for speech-language therapy services, including lactation, is ultimately the responsibility of the client. Reimbursement is not guaranteed but will depend on the insurance policy.
Hannah Walsh, MS CCC-SLP, CLC will provide assistance, within reason of their sole discretion, to client by providing copies of necessary documents such as invoices or proof of treatment. Additional fees may apply if therapist is required to communicate with your insurance company and exceeds 15 minutes.

Cancellation
To reschedule or cancel, please use scheduling feature via website. If needing to cancel or reschedule, Hannah Walsh, MS CCC-SLP, CLC should know at least 24 hours before the appointment time. Cancellation less than 24 hours before my appointment will result in a cancellation fee of $50. Cancellation fees are not eligible for insurance reimbursement.

Communication
Regular text and email are not secure forms of communication. If choosing to communicate through these mediums, therapist will respond through that medium.

Any third party included on any email, text, or other communication with Hannah Walsh, MS CCC-SLP, CLC is granting permission for therapist to communicate my protected health information and that of my baby or babies with that third party. Hannah Walsh, MS CCC-SLP, CLC will not initiate inclusion of any third party on an email or text. I acknowledge that Hannah Walsh, MS CCC-SLP, CLC is not responsible for any breach of confidentiality made by any person I invite to be present during a visit, or added by me as a third party to text, email or other modes of communication.