Completion of Electronic Forms and Signatures: I understand that electronic forms and signatures are to be completed and signed in their entirety to the best of my ability at least 24 hours in advance of my scheduled appointment; if the appointment is scheduled same day, demographic information and  signatures are required as soon as possible and prior to visit start time. Breast Assured Lactation LLC reserves the right to cancel appointments if forms are not completed within this time frame.

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Credit Card on File: I understand that a credit card will be required at the time of booking to hold my appointment. I understand that Breast Assured Lactation LLC may communicate with my credit card company or bank for any payment related matters and that it is my responsibility to provide accurate and current payment information.

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Cancellation Policy: Breast Assured Lactation LLC kindly requests more than 24 hours notice for any cancellations. I understand that a late cancellation fee of $100 will be charged automatically to my credit card on file for any cancellation that occurs in less than 24 hours. In the event of clinician illness, I understand that Breast Assured Lactation LLC will notify me as soon as able and will offer a virtual visit (where applicable) or an opportunity to reschedule.

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Travel Fees: I understand that Breast Assured Lactation LLC generally offers home visits in the Delaware County region but that accommodations can sometimes be made for areas beyond this radius depending on availability. Suburban locations beyond the general service area will incur a $25 per visit travel fee while Philadelphia and Wilmington locations will incur $35 per visit travel fee. I understand that I will be informed about whether the travel fee will apply to me before my first visit and that this fee is not covered or able to be reimbursed by insurance. I understand that this fee may be paid in cash, check or via credit card at the time of my visit but that an additional transaction fee of 3.6% will be applied if I choose to use a credit card.

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Breastfeeding Products and Supplies: I understand that Breast Assured Lactation LLC carries a select assortment of breastfeeding supplies and products as a convenience for clients (such as Maymom flanges, connectors, pumping spray, nipple shields, feeding sets and bottles). I understand that these supplies and products are not covered by any insurance providers, although in Pennsylvania they are considered tax exempt and I may request a receipt. I understand that I am not obligated to purchase anything from Breast Assured Lactation LLC. If I choose to purchase products I agree to pay for any supplies upon receipt via cash or check. I understand that my credit card on file may be used (via Square*) but that this will incur an additional transaction fee of 3.6%.

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AETNA CLIENTS - In Network Provider 

I understand that Breast Assured Lactation LLC is an in-network provider with Aetna. I understand that I am responsible to verify my own lactation benefits by contacting my insurance company directly to verify lactation coverage in advance of my visit. I understand that Breast Assured Lactation LLC will be unable to provide me with additional information as to my specific benefits and covered services. 

I understand that I am responsible to promptly alert Breast Assured Lactation LLC of any changes in my insurance plan. I understand that Breast Assured Lactation LLC partners with a third party billing service known as “Sunshyn Credentialing” and that this service will submit claims to Aetna on my behalf. 

I further understand that  if my plan denies coverage of lactation services after the claims have been submitted, I will be responsible to pay the remaining balance. I understand that Aetna may only cover a portion of my lactation visits and I agree to the financial responsibility of paying the balance directly to Breast Assured Lactation LLC. I understand that claims are not processed immediately and sometimes the remaining balance may not be known until 120 days or more after my visit. I agree that Breast Assured Lactation LLC and Sunshyn Credentialing may communicate with Aetna directly in reference to the services provided to me and my baby or babies.

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INDEPENDENCE BLUE CROSS CLIENTS - In Network Provider

I understand that Breast Assured Lactation LLC is an in-network provider with Independence Blue Cross. I understand that I am responsible to verify my own lactation benefits by contacting my insurance company directly to verify lactation coverage in advance of my visit. I understand that Breast Assured Lactation LLC will be unable to provide me with additional information as to my specific benefits and covered services. I understand that I am responsible to promptly alert Breast Assured Lactation LLC of any changes in my insurance plan. I understand that Breast Assured Lactation LLC partners with a third party billing service known as “Sunshyn Credentialing” and that this service will submit claims to Independence Blue Cross on my behalf. I further understand that if my plan denies coverage of lactation services after the claims have been submitted, I will be responsible to pay the remaining balance. I understand that Independence Blue Cross may only cover a portion of my lactation visits and I agree to the financial responsibility of paying the balance directly to Breast Assured Lactation LLC. I understand that claims are not processed immediately and sometimes the remaining balance may not be known until 120 days or more after my visit. I agree that Breast Assured Lactation LLC and Sunshyn Credentialing may communicate with Independence Blue Cross directly in reference to the services provided to me and my baby or babies.

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THE LACTATION NETWORK (TLN) CLIENTS (United Healthcare)

Breast Assured Lactation LLC is a proud partner with The Lactation Network (TLN). Once insurance eligibility has been determined with TLN, an appointment may be scheduled with Breast Assured Lactation LLC. I understand that TLN will handle billing directly with my insurance company and that Breast Assured Lactation LLC will not communicate directly with my insurance company. I understand that when using TLN I must choose one lactation consultant/company and that I must never schedule more than one lactation consultation per day.  I understand that I will not owe anything at the time of the appointment and that I should not receive a bill (except in instances where more than one consultant has been paired and/or more than one consultation has been scheduled on the same day).  I understand that I may receive an “Explanation of Benefits” after the appointment and if I have questions I should direct them to TLN and not Breast Assured Lactation LLC. I understand that I am responsible for keeping TLN updated as to any changes in my insurance plan and that they need accurate information regarding both the insurance of myself and my baby/babies (if different).. I further understand that in some cases, telehealth services may not be covered but that TLN will inform me of this in advance. 

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Wildflower CLIENTS (Cigna) 

Breast Assured Lactation LLC is a proud partner with Wildflower. Once insurance eligibility has been determined with Wildflower, an appointment may be scheduled with Breast Assured Lactation LLC. I understand that Wildflower will handle billing directly with my insurance company and that Breast Assured Lactation LLC will not communicate directly with my insurance company. I understand that when using Wildflower I must choose one lactation consultant/company and that I must never schedule more than one lactation consultation per day.  I understand that I will not owe anything at the time of the appointment and that I should not receive a bill (except in instances where more than one consultant has been paired and/or more than one consultation has been scheduled on the same day).  I understand that I may receive an “Explanation of Benefits” after the appointment and if I have questions I should direct them to Wildflower and not Breast Assured Lactation LLC. I understand that I am responsible for keeping Wildflower updated as to any changes in my insurance plan and that they need accurate information regarding both the insurance of myself and my baby/babies (if different).. I further understand that in some cases, telehealth services may not be covered but that Wildflower will inform me of this in advance. 

 

*Privacy Note regarding Square for Credit Card Transactions: Payments may be made electronically using a credit card or fund transfer. Breast Assured Lactation LLC uses Square to process credit card payments. Square meets the high standards of HIPAA and the banking industry for security and privacy with regard to financial transactions. However, Square 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. Square will be used to process cancellation charges but only the date and cancellation fee would be visible on any receipts generated for this purpose.