Payment policy
Self-pay (out-of-network) clients:
I will provide you with a superbill suitable for you to submit to your insurance. The superbill (which will also serve as a payment receipt) will be coded appropriately to the level of service provided during the visit. You agree to pay me at the time of the visit (cash, check, credit card, or FSA).
Love Flows Lactation is providing care to me and to my baby or babies; together we are all the client of Love Flows Lactation.
My initial visit includes 2-4 weeks of follow up support by secure messaging, email, or text. Continued support is available for a weekly fee of $25.00. These fees are elective and not eligible for insurance reimbursement.
If my location has a travel fee applied, I understand that this is not eligible for insurance reimbursement.
I am responsible to verify my own lactation benefits. Love Flows Lactation can only see that I have benefits, they cannot see if I have any special circumstances that might prevent my insurance provider from covering services. If my plan denies coverage of lactation services after the claims have been submitted, I am responsible to pay at the self-pay rate. I understand I should refer to my plan benefits and call my insurance directly to verify lactation coverage.
Love Flows Lactation may communicate with my insurance company in reference to the services provided to me and my baby or babies. Love Flows Lactation may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information. I will update my credit card information as needed and am responsible for any costs and fees associated with my failure to provide updated information.
These policies apply to Love Flows Lactation and its representatives.
Payments may be made electronically using a credit card or fund transfer. I use SquareUp to process payments. SquareUp meets the high standards of HIPAA and the banking industry for security and privacy with regard to financial transactions. However, SquareUp may send, automatically or per your request, email or text message receipts that reveal personal health information such as the date and type of lactation visit. If you are not comfortable with this, payment may be made via cash or check instead.
Cancellation policy: I understand that I am responsible for all charges associated with this visit. If I cancel with less than 24 hours notice, my credit card on file will be charged $50.00.
I will provide you with a superbill suitable for you to submit to your insurance. The superbill (which will also serve as a payment receipt) will be coded appropriately to the level of service provided during the visit. You agree to pay me at the time of the visit (cash, check, credit card, or FSA).
Love Flows Lactation is providing care to me and to my baby or babies; together we are all the client of Love Flows Lactation.
My initial visit includes 2-4 weeks of follow up support by secure messaging, email, or text. Continued support is available for a weekly fee of $25.00. These fees are elective and not eligible for insurance reimbursement.
If my location has a travel fee applied, I understand that this is not eligible for insurance reimbursement.
I am responsible to verify my own lactation benefits. Love Flows Lactation can only see that I have benefits, they cannot see if I have any special circumstances that might prevent my insurance provider from covering services. If my plan denies coverage of lactation services after the claims have been submitted, I am responsible to pay at the self-pay rate. I understand I should refer to my plan benefits and call my insurance directly to verify lactation coverage.
Love Flows Lactation may communicate with my insurance company in reference to the services provided to me and my baby or babies. Love Flows Lactation may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information. I will update my credit card information as needed and am responsible for any costs and fees associated with my failure to provide updated information.
These policies apply to Love Flows Lactation and its representatives.
Payments may be made electronically using a credit card or fund transfer. I use SquareUp to process payments. SquareUp meets the high standards of HIPAA and the banking industry for security and privacy with regard to financial transactions. However, SquareUp may send, automatically or per your request, email or text message receipts that reveal personal health information such as the date and type of lactation visit. If you are not comfortable with this, payment may be made via cash or check instead.
Cancellation policy: I understand that I am responsible for all charges associated with this visit. If I cancel with less than 24 hours notice, my credit card on file will be charged $50.00.
CONSENT FOR CARE FOR TELELACTATION
I understand that during a virtual consult for lactation support, Latasha Marston, CLEC, IBCLC may examine me and my breasts visually, may examine me and my baby or babies visually, may observe me and my baby while feeding, may make clinical observations, may provide information on techniques and breastfeeding, pumping, and feeding equipment, and will make recommendations towards helping me reach my goals. Latasha Marston, CLEC, IBCLC will guide me in positioning my camera to be able to see me and my baby, and will direct me in assessments of my breasts and/or my baby in the furtherance of my care.
I understand no outcome can be guaranteed. I acknowledge that there may be some limitations with virtual care.
I will provide Latasha Marston, CLEC, IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Latasha Marston, CLEC, IBCLC may communicate with them. It is my responsibility to provide accurate information and to keep it updated.
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 Latasha Marston, CLEC, IBCLC of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Latasha Marston, CLEC, IBCLC, I am granting permission for Latasha Marston, CLEC, IBCLC to communicate my health information and that of my baby or babies with that third party. Latasha Marston, CLEC, IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Latasha Marston, CLEC, IBCLC is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.
I have read and reviewed Latasha Marston, CLEC, IBCLC’s payment policies and understand that I am responsible for all charges associated with this visit. Latasha Marston, CLEC, IBCLC is providing care to me and to my baby or babies; together we are all the client of Latasha Marston, CLEC, IBCLC. Latasha Marston, CLEC, IBCLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. Latasha Marston, CLEC, IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.
I give permission to Latasha Marston, CLEC, IBCLC to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.
I am aware that Latasha Marston, CLEC, IBCLC is a Certified Lactation Educator Counselor certified by University of California, San Diego and an International Board Certified Lactation Consultant (IBCLC). I understand that if a case becomes too complex, Latasha Marston, CLEC, IBCLC, will refer my case to a knowledgeable IBCLC in my area of need and transfer my care. I understand that should this occur, I will still be responsible for payment of any invoices outstanding for services rendered.
I understand no outcome can be guaranteed. I acknowledge that there may be some limitations with virtual care.
I will provide Latasha Marston, CLEC, IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Latasha Marston, CLEC, IBCLC may communicate with them. It is my responsibility to provide accurate information and to keep it updated.
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 Latasha Marston, CLEC, IBCLC of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Latasha Marston, CLEC, IBCLC, I am granting permission for Latasha Marston, CLEC, IBCLC to communicate my health information and that of my baby or babies with that third party. Latasha Marston, CLEC, IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Latasha Marston, CLEC, IBCLC is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.
I have read and reviewed Latasha Marston, CLEC, IBCLC’s payment policies and understand that I am responsible for all charges associated with this visit. Latasha Marston, CLEC, IBCLC is providing care to me and to my baby or babies; together we are all the client of Latasha Marston, CLEC, IBCLC. Latasha Marston, CLEC, IBCLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. Latasha Marston, CLEC, IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.
I give permission to Latasha Marston, CLEC, IBCLC to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.
I am aware that Latasha Marston, CLEC, IBCLC is a Certified Lactation Educator Counselor certified by University of California, San Diego and an International Board Certified Lactation Consultant (IBCLC). I understand that if a case becomes too complex, Latasha Marston, CLEC, IBCLC, will refer my case to a knowledgeable IBCLC in my area of need and transfer my care. I understand that should this occur, I will still be responsible for payment of any invoices outstanding for services rendered.
Consent for care for In Person
I understand that during a consult for lactation support, Latasha Marston, CLEC, IBCLC will examine me and my breasts both visually and manually, will examine me and my baby or babies both visually and manually (including an oral exam with a gloved finger), will observe me and my baby while feeding, will make clinical observations, will provide information on techniques and breastfeeding equipment, and will make recommendations towards helping me reach my breastfeeding goals. I understand no outcome can be guaranteed.
I will provide Latasha Marston, CLEC, IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Latasha Marston, CLEC, IBCLC may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Latasha Marston, CLEC, IBCLC to send and receive texts and emails that may contain my Personal Health Information (PHI).
Because Latasha Marston, CLEC, IBCLC will be coming to my home, I grant permission for Latasha Marston, CLEC, IBCLC to give my address to Donovan Marston, and I understand that Latasha Marston, CLEC, IBCLC will use GPS to navigate to my home.
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 Latasha Marston, CLEC, IBCLC of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Latasha Marston, CLEC, IBCLC I am granting permission for Latasha Marston, CLEC, IBCLC to communicate my health information and that of my baby or babies with that third party. Latasha Marston, CLEC, IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Latasha Marston, CLEC, IBCLC is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.
I have read and reviewed Latasha Marston, CLEC, IBCLC’s payment policies and understand that I am responsible for all charges associated with this visit. Latasha Marston, CLEC, IBCLC is providing care to me and to my baby or babies; together we are all the client of Latasha Marston, CLEC, IBCLC. Latasha Marston, CLEC, IBCLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. Latasha Marston, CLEC, IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.
I give permission to Latasha Marston, CLEC, IBCLC to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.
I will provide Latasha Marston, CLEC, IBCLC with the names and contact information for other relevant healthcare providers for me and my baby, and Latasha Marston, CLEC, IBCLC may communicate with them. It is my responsibility to provide accurate information and to keep it updated. I understand that email and text are not secure means of communication, and give my permission for Latasha Marston, CLEC, IBCLC to send and receive texts and emails that may contain my Personal Health Information (PHI).
Because Latasha Marston, CLEC, IBCLC will be coming to my home, I grant permission for Latasha Marston, CLEC, IBCLC to give my address to Donovan Marston, and I understand that Latasha Marston, CLEC, IBCLC will use GPS to navigate to my home.
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 Latasha Marston, CLEC, IBCLC of any person(s) I wish to have present during the visit. I understand that if I include any third party on an email or text with Latasha Marston, CLEC, IBCLC I am granting permission for Latasha Marston, CLEC, IBCLC to communicate my health information and that of my baby or babies with that third party. Latasha Marston, CLEC, IBCLC will not initiate inclusion of any third party on an email or text. I acknowledge that Latasha Marston, CLEC, IBCLC is not responsible for any breach of confidentiality made by any person present I invite to be present during a visit, or added by me as a third party to text or email.
I have read and reviewed Latasha Marston, CLEC, IBCLC’s payment policies and understand that I am responsible for all charges associated with this visit. Latasha Marston, CLEC, IBCLC is providing care to me and to my baby or babies; together we are all the client of Latasha Marston, CLEC, IBCLC. Latasha Marston, CLEC, IBCLC may communicate with my insurance company in reference to the services provided to me and my baby or babies. Latasha Marston, CLEC, IBCLC may communicate with my credit card company or bank for any payment related matters. It is my responsibility to provide accurate and current payment and insurance information.
I give permission to Latasha Marston, CLEC, IBCLC to photograph or record video of me and/or my baby in furtherance of my care. These photos will not be published without my express consent, but they may be shared with my or my baby’s healthcare team.
privacy
Notice of Privacy Practices: Effective June 1, 2020 Privacy Officer for Love Flows Lactation Latasha Marston, all concerns and requests can be directed to latasha@loveflowslac.com
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
In these cases we never share your information unless you give us written permission:
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Any issues or requests should be directed to latasha@loveflowslac.com
Your Rights
You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures
We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
- Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
- Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days. Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
- Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
- Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
- Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
- Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. *We will make sure the person has this authority and can act for you before we take any action.
- File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting
- We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.
- Treat you
- We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.
- Run our organization. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: We use health information about you to manage your treatment and services.
- Bill for your services: We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
- Do research
- We can use or share your information for health research.
- Comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
- Respond to organ and tissue donation requests:We can share health information about you with organ procurement organizations.
- Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
- Address workers’ compensation, law enforcement, and other government requests
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
- Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Any issues or requests should be directed to latasha@loveflowslac.com
Affiliate links
- If you click a link on my website which takes you to a third party site and you make a purchase, I may make a small commission at no additional cost to you. I only recommend products that I have used personally or have researched extensively and feel confident in suggesting.
- I may get referral or discount codes which I may post. This is essentially the same as you clicking an affiliate link and completing a purchase– I may make small commission at no additional cost to you.