Forms & Policies

Please read policy statements below.
An appointment confirmation email will be issued
after all required forms have been completed.

Therapeutic Ultrasound Referral

Notice of Privacy Practices

Thrive Lactation, LLC NOTICE OF PRIVACY PRACTICES EFFECTIVE DATE: January 1, 2018 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. UNDERSTANDING YOUR HEALTH RECORD/INFORMATION Each time you visit a hospital, physician, dentist, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who contribute to your care. Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and helps you make more informed decisions when authorizing disclosure to others. YOUR HEALTH INFORMATION RIGHTS Unless otherwise required by law, your health record is the physical property of the healthcare practitioner or facility that compiled it. However, you have certain rights with respect to the information. You have the right to: Receive a copy of this Notice of Privacy Practices from us upon enrollment or upon request. Request restrictions on our uses and disclosures of your protected health information for treatment, payment and health care operations. However, we reserve the right not to agree to the requested restriction. Request to receive communications of protected health information in confidence. Inspect and obtain a copy of the protected health information contained in your medical and billing records and in any other Practice records used by us to make decisions about you. A reasonable copying charge may apply. Request an amendment to your protected health information. However, we may deny your request for an amendment, if we determine that the protected health information or record that is the subject of the request: • was not created by us, unless you provide a reasonable basis to believe that the originator of the protected health information is no longer available to act on the requested amendment; is not part of your medical or billing records; is not available for inspection as set forth above; or is accurate and complete. In any event, any agreed upon amendment will be included as an addition to, and not a replacement of, already existing records. Receive an accounting of disclosures of protected health information made by us to individuals or entities other than to you, except for disclosures: to carry out treatment, payment and health care operations as provided above; to persons involved in your care or for other notification purposes as provided by law; to correctional institutions or law enforcement officials as provided by law; for national security or intelligence purposes; that occurred prior to the date of compliance with privacy standards (April 14, 2003); incidental to other permissible uses or disclosures; that are part of a limited data set (does not contain protected health information that directly identifies individuals); made to patient or their personal representatives; for which a written authorization form from the patient has been received Revoke your authorization to use or disclose health information except to the extent that we have already been taken action in reliance on your authorization, or if the authorization was obtained as a condition of obtaining insurance coverage and other applicable law provides the insurer that obtained the authorization with the right to contest a claim under the policy. OUR RESPONSIBILITIES We are required to maintain the privacy of your health information. In addition, we are required to provide you with a notice of our legal duties and privacy practices with respect to information we collect and maintain about you. We must abide by the terms of this notice. We reserve the right to change our practices and to make the new provisions effective for all the protected health information we maintain. If our information practices change, a revised notice will be mailed to the address you have supplied upon request. If we maintain a Web site that provides information about our patient/customer services or benefits, the new notice will be posted on that Web site. Your health information will not be used or disclosed without your written authorization, except as described in this notice. Except as noted above, you may revoke your authorization in writing at any time. FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions about this notice or would like additional information, you may contact our Privacy Officer at the telephone or address below. If you believe that your privacy rights have been violated, you have the right to file a complaint with the practice’s Privacy Officer or with the Secretary of the Department of Health and Human Services. We will take no retaliatory action against you if you make such complaints. The contact information for both is included below. U.S. Department of Health and Human Services Office of the Secretary 200 Independence Avenue, S.W. Washington, D.C. 20201 Tel: (202) 619-0257 Toll Free: 1-877-696-6775

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Consent for Treatment

CONSENT FOR TREATMENT THRIVE LACTATION, LLC Consent Agreement to be READ, SIGNED & SUBMITTED before the lactation counseling visit will be confirmed. I understand the 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 lactation visit includes a detailed history of mother/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 lactation counselor each have responsibilities in this plan. 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 that I am responsible for informing the lactation counselor 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 lactation counselor with progress reports, questions or concerns. I understand any instructions or recommendations given may be discussed with one or both of our health care providers. I understand a partial or follow-up visit is sometimes necessary. I understand that breastfeeding supplies and/or breast pumps may be recommended as effective management of specific situations. Only effective equipment will be recommended. I authorize the lactation counselor to release any information acquired in the evaluation and/or management of myself and/or my child to our health care providers, referring physician, referring lay breastfeeding counselor, and/or our insurance company upon request. I understand the lactation counselor may contact my physician or my child’s physician if the lactation counselor feels it is necessary to consult with the physician. I understand that if I choose to have an end-to-end encrypted Video-Call consult, any internet based communication is not guaranteed to be secure and agree to the risks associated with this type of communication I have received a copy of the lactation counselor’s HIPAA Privacy Practices. I have reviewed and agree with the terms of Thrive Lactation, LLC's Cancellation Policy. Consent will remain active during the course of care, unless revoked in writing to Thrive Lactation, LLC. I understand this practice only accepts fee for service, at time of service. It is my responsibility to pursue reimbursement for lactation services from my insurance company. This practice does not currently bill for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but will depend on your policy. Filing a claim is suggested even if you feel it will not be a covered benefit in your policy. To sign, enter first & last name in field below.

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Cancellation & Billing Policy - The Lactation Network

Cancellation & Billing Policy The Lactation Network - Approved Clients Cancellation Policy to be READ, SIGNED & SUBMITTED to confirm your appointment date & time. I understand this practice requires payment of fee for service, at the time of service for any visits completed prior to receiving The Lactation Network, (referred to herein as TLN) verification of coverage. A travel fee shall apply to all home visits at an address greater than 5 miles from 317 NW Gilman Blvd, Issaquah, WA 98027. In the event of non-coverage by TLN, it is my responsibility to pursue reimbursement for lactation services from my insurance company. This practice does not directly bill for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but will depend on my policy. *Filing a claim is suggested even if you feel it will not be a covered benefit in your policy. For fees not covered by TLN, Thrive Lactation, LLC accepts payment by all major credit cards. Health Saving Account (HSA) or Flexible Spending Account (FSA) credit cards are also accepted if deemed a qualified medical expense by your insurance provider. If you need to make other payment arrangements, such as payment by cash or check, please give us a call. In the event that you need to cancel or reschedule your appointment, please email hello@thriveissaquah.com to notify us. We accept cancellations with a minimum of 24 hours notice. When an appointment time is reserved for you, our counselors, schedule and clinic space are assigned accordingly. Late cancellations and no-shows utilize time that could otherwise be offered to another family in need. Late cancellations and no-shows will result in forfeiture of the appointment fee. Fees will be charged to the credit card on file. By providing my credit card information at the time of booking, I authorize Thrive Lactation, LLC to charge my card for all consultations and supplies, as well as fees for appointments not canceled at least 24 hours in advance. I understand that after hours appointments, scheduled Monday-Friday after 5:00pm, on weekends or holidays are subject to a 30% surcharge. A receipt for all charges will be provided to me. I understand that this account is my responsibility. I understand that outstanding balances over 120 days may be referred to an appropriate collection agency. I have read and agree to the terms of the cancellation and billing policy as outlined above.

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Cancellation & Billing Policy - Self Pay

Cancellation & Billing Policy to be READ, SIGNED & SUBMITTED to confirm your appointment date & time. I understand this practice only accepts fee for service, at the time of service. It is my responsibility to pursue reimbursement for lactation services from my insurance company. This practice does not currently bill for insurance reimbursement and is not a provider on any insurance plan. Reimbursement is not guaranteed, but will depend on my policy. *Filing a claim is suggested even if you feel it will not be a covered benefit in your policy. Thrive Lactation, LLC accepts payment by all major credit cards. Health Saving Account (HSA) or Flexible Spending Account (FSA) credit cards are also accepted if deemed a qualified medical expense by your insurance provider. If you need to make other payment arrangements, such as payment by cash or check, please give us a call. In the event that you need to cancel or reschedule your appointment, please email hello@thriveissaquah.com to notify us. We accept cancellations with a minimum of 24 hours notice. When an appointment time is reserved for you, our counselors, schedule and clinic space are assigned accordingly. Late cancellations and no-shows utilize time that could otherwise be offered to another family in need. Late cancellations and no-shows for private visits will result in forfeiture of the full appointment fee. Fees will be charged to the credit card on file. By providing my credit card information at the time of booking, I authorize Thrive Lactation, LLC to charge my card for all consultations and supplies, as well as fees for appointments not canceled at least 24 hours in advance. I understand that after hours appointments, scheduled Monday-Friday after 5:00pm, on weekends or holidays are subject to a 30% surcharge. A receipt for all charges will be provided to me. I understand that this account is my responsibility. I understand that outstanding balances over 120 days may be referred to an appropriate collection agency. I have read and agree to the terms of the cancellation and billing policy as outlined above.

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