Payment Policy
Agreement for Self-Payment of Services
Equipped to Flourish is committed to providing the best quality lactation services. We do not participate in any insurance plans, including Medicare or Medicaid, and we do not accept any health insurance whatsoever. Our services are 100% self-pay by our patients. By signing this form, you acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) you have health insurance but you do not want to use any insurance benefit for these services, acknowledging that Equipped to Flourish does not accept any health insurance.
Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By signing this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider. You have selected services for purchase from us on a self-pay basis. In other words, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.
Equipped to Flourish has provided you with the charges, in advance, for the services you have requested. By signing below, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment.
Equipped to Flourish requires payment in full when services are booked. Due to the inconvenience cancellations cause, 50% of the charged fee will be applied to your card if you cancel or reschedule your appointment with less than 48 hours notice. An appointment “no-show” will result in a charge to your card on file for the full cost of the visit. Opportunity for rescheduling is not guaranteed, although every effort to accommodate clients who are actively communicating with me will be made.
Consent for Care for Telelactation
I understand that during a virtual consult for lactation support, Thea Simpson 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. Thea Simpson 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 Thea Simpson with the names and contact information for other relevant healthcare providers for me and my baby, and Thea Simpson 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 Thea Simpson 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 Thea Simpson, I am granting permission for Thea Simpson to communicate my health information and that of my baby or babies with that third party. Thea Simpson will not initiate inclusion of any third party on an email or text. I acknowledge that Thea Simpson 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 Thea Simpson’s payment policies and understand that I am responsible for all charges associated with this visit. Thea Simpson is providing care to me and to my baby or babies; together we are all the client of Thea Simpson. Thea Simpson may communicate with my insurance company in reference to the services provided to me and my baby or babies. Thea Simpson 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 Thea Simpson 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.
Consent For Care for In-Person Lactation Visits
I understand that during a consult for lactation support, Thea Simpson 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 Thea Simpson with the names and contact information for other relevant healthcare providers for me and my baby, and Thea Simpson 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 Thea Simpson to send and receive texts and emails that may contain my Personal Health Information (PHI).
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 Thea Simpson 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 Thea Simpson, I am granting permission for Thea Simpson to communicate my health information and that of my baby or babies with that third party. Thea Simpson will not initiate inclusion of any third party on an email or text. I acknowledge that Thea Simpson 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 Thea Simpson’s payment policies and understand that I am responsible for all charges associated with this visit. Thea Simpson is providing care to me and to my baby or babies; together we are all the client of Thea Simpson. Thea Simpson may communicate with my insurance company in reference to the services provided to me and my baby or babies. Thea Simpson 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 Thea Simpson 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.
Secure Messaging
Thea Simpson provides a secure messaging portal through Charm Connect. I understand that I am not obligated to use secure messaging, and if I opt out of secure messaging by initiating communication by text or email Thea Simpson will respond. I understand that email and text are not secure means of communication and give my permission for Thea Simpson to send and receive texts and emails that may contain my Personal Health Information (PHI) if initiated by me.
Website Terms and Conditions of Use
This page states the Terms and Conditions under which you, the website visitor (hereinafter “you” or “visitor”), may use this site, the content of which is owned by or licensed to Equipped to Flourish. By using this site, you agree to be bound by all of the Terms and Conditions set forth below. If you do not accept these Terms and Conditions, please do not use this site. Equipped to Flourish may, at its sole discretion, revise these Terms and Conditions at any time; therefore, you should visit this page periodically to review the Terms and Conditions.
Equipped to Flourish seeks to: provide a safe space to learn and grow in the lactation journey. Whether your family is looking at becoming pregnant, have recently delivered and are lactating, or are looking to have a different lactation experience with subsequent children, we are here to support.
Although Equipped to Flourish strives for timeliness and accuracy in all of its materials, Equipped to Flourish makes no representations, warranties, or assurances as to the availability, accuracy, currency, or completeness of this site or its contents. Equipped to Flourish shall not be liable for any damages or injury resulting from your access to, inability to access, or use of this site, including, without limitation, any damages or injury arising from any links to other sites contained within or referred to in this site.
Privacy
Equipped to Flourish is committed to preserving your right to privacy. Equipped to Flourish does not collect identifying information about you (such as your name, address, telephone number, or email address) unless you voluntarily submit that information to us through our Contact Us page, our newsletter subscription pages, or other means.
Please do not provide any confidential information (including health information) to us via electronic communication. Any information you do submit will not be sold to any third parties. If we publish any information you provide to us on the website, we will only disclose personally identifiable information agreed upon by you.
We use “cookies” on this site. A cookie is a piece of data stored on a site visitor’s hard drive to help us improve your access to our site and identify repeat visitors to our site. For instance, when we use a cookie to identify you, you would not have to log in a password more than once, thereby saving time while on our site. Cookies can also enable us to track and target the interests of our users to enhance the experience on our site. Usage of a cookie is in no way linked to any personally identifiable information on our site.
If you are concerned about the information You have provided to Equipped to Flourish or would like to review, update, or delete that information, please contact us at admin@equippedtoflourish.com. Equipped to Flourish will make reasonable efforts to comply with your wishes.
Contact Us and “Ask an Expert”
The Contact Us page is the primary means of communication with Equipped to Flourish for a website visitor. Website visitors may use the Contact Us page to send questions or content suggestions to us. Any health information submitted through the Contact Us pages is not stored in a way that is personally identifiable. We may, unless you indicate otherwise, store, edit, and excerpt your email for use in Q&As, presentations, analyses, and other similar purposes. In these cases, we will delete any content that would specifically identify you as the writer of the email.
The information provided through the Website is for educational purposes only and should not be considered medical advice. It is not meant to replace the advice of the physician who cares for you or your child. All medical advice and information should be considered to be incomplete without a physical exam, which is not possible without a visit to your doctor.
Medical Disclaimer
The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. Equipped to Flourish makes no representation and assumes no responsibility for the accuracy of information contained on or available through this website, and such information is subject to change without notice. All information provided on the website is general information provided for educational purposes. You are encouraged to confirm any information obtained from or through this website with other sources, and review all information regarding any medical condition or treatment with your child’s physician. Never disregard professional medical advice or delay medical treatment because of something you have read on this website.
Newsletters
The only personally identifiable information that is actively collected by Equipped to Flourish is email addresses of individuals who opt-in to our newsletter programs. These email addresses are only used for delivering our newsletters. Users may remove their email address from our list by using the unsubscribe link provided at the bottom of each newsletter.
User Submissions
Equipped to Flourish welcomes your comments on its site and content. However, you acknowledge that if you send us suggestions, ideas, notes, drawings, concepts, photographs, or other information (collectively, the “Information”), the Information shall be deemed, and shall remain, the property of Equipped to Flourish. By submission of any Information to us, you assign to us and we shall exclusively own all now known or hereafter existing rights to such Information and shall be entitled to unrestricted use of the Information for any purpose whatsoever, commercial or otherwise, without compensation to you.
As a user of this site, you are responsible for your own communications and are responsible for the consequences of their posting. Therefore, do not do any of the following: transmit to us material that is copyrighted, unless you are the copyright owner or have the permission of the copyright owner to post it; send material that reveals trade secrets, unless you own them or have the permission of the owner; send material that infringes on any other intellectual property rights of others or on the privacy or publicity rights of others; send material that is obscene, defamatory, threatening, harassing, abusive, hateful, or embarrassing to another user or any other person or entity; send sexually explicit images; send advertisements or solicitations of business; send chain letters or pyramid schemes; or impersonate another person.
Equipped to Flourish reserves the right to expel users and prevent their further access to this site for violating these terms or the law and reserves the right to remove any communications from this site. The violation of any of the terms and conditions set forth on this Terms and Conditions page shall result in the immediate revocation of your right to use the content and obligates you to immediately destroy any copies of the content in your possession.
Links
This site contains links to websites owned by third parties. These links are provided solely as a convenience to you and are not an endorsement by Equipped to Flourish of the contents of those other sites. Equipped to Flourish is not responsible for the content of any linked sites and makes no representations regarding the content or accuracy of materials on such sites. If you decide to visit any third-party sites using links from this site, you do so at your own risk.
Equipped to Flourish does not recommend, endorse, or make any representation about the efficacy, appropriateness, or suitability of any specific tests, products, procedures, treatments, services, opinions, health care providers, or other information that may be contained on or available through this website. Equipped to Flourish is not responsible nor liable for any advice, diagnosis, treatment, or any other information, services, or products that you obtain through this website.
Disclaimer of Warranties
Equipped to Flourish does not warrant that the site will operate error-free or that the site or its server are free of computer viruses or other harmful material. If your use of the site or the site’s material results in the need for servicing or replacing of equipment or data, Equipped to Flourish shall not be responsible for those costs. This site and its material are provided on an “as is” basis without any warranties of any kind. Equipped to Flourish, to the fullest extent permitted by law, disclaims all warranties, including the warranty of merchantability, non-infringement of third parties’ rights, and the warranty of fitness for a particular purpose.
Disclaimer of Consequential Damages
In no event shall Equipped to Flourish, its medical consultants, or any third parties mentioned in the site content be liable for any damages whatsoever (including, without limitation, incidental, consequential, or punitive damages, lost profits, or damages resulting from lost data or business interruption) resulting from the use or inability to use material on this website or sites linked to this website whether based on warranty, contract, tort, or any other legal theory, and whether Equipped to Flourish is advised of the possibility of such damages.
Use of Site Material
The contents of this site, including, without limitation, text, graphics, images, and other content (the “Content”) are owned by or licensed to Equipped to Flourish and are protected by copyright under both United States and foreign laws. Unauthorized use of the Content violates copyright, trademark, and other laws. You agree to retain all copyright and other proprietary notices contained in the original Content on any copy you make of such material. You may not sell or modify our Content or reproduce, display, distribute, or otherwise use the Content in any way for any public or commercial purpose. Use of the Content on any other website or in a networked environment is prohibited.
Miscellaneous
This site originates from within the United States. Equipped to Flourish does not claim that the Content on this site is appropriate or may be used outside of the United States. Access to the Content may not be legal by certain persons or in certain countries. If you access the site from outside the United States, you do so at your own risk and are responsible for compliance with the laws of your jurisdiction.
These Terms and Conditions are governed by the substantive laws of the State of << Insert Your State Here>>, without respect to its conflict of laws principles. You agree to submit to the jurisdiction of the courts situated in the State of << Insert Your State Here>> with respect to any dispute, disagreement, or cause of action related to or involving this site. If any provision is found to be invalid by any court having competent jurisdiction, the invalidity of such provision shall not affect the validity of the remaining provisions of these Terms and Conditions, which shall remain in full force and effect. No waiver of any of these Terms and Conditions shall be deemed a further or continuing waiver of such term or any other term. Except as expressly provided elsewhere in this site, these Terms and Conditions constitute the entire agreement between you and Equipped to Flourish with respect to your use of this site.
Your Information. Your Rights. Our Responsibilities.
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.
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 Equipped to Flourish share
- Get a list of those with whom Equipped to Flourish 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 Equipped to Flourish use and share information as Equipped to Flourish:
- 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
- Equipped to Flourish may use and share your information as Equipped to Flourish:
Treat you - Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- 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 Equipped to Flourish have about you. Ask us how to do this.
- Equipped to Flourish will provide a copy or a summary of your health information, usually within 30 days of your request. Equipped to Flourish 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.
- Equipped to Flourish may say “no” to your request, but Equipped to Flourish will 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.
- Equipped to Flourish will say “yes” to all reasonable requests.
Ask us to limit what Equipped to Flourish use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. Equipped to Flourish are not required to agree to your request, and Equipped to Flourish 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. Equipped to Flourish will say “yes” unless a law requires us to share that information.
Get a list of those with whom Equipped to Flourish has shared information
- You can ask for a list (accounting) of the times Equipped to Flourish has shared your health information for six years prior to the date you ask, who Equipped to Flourish shared it with, and why.
- Equipped to Flourish 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). Equipped to Flourish’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. Equipped to Flourish 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.
- Equipped to Flourish will make sure the person has this authority and can act for you before Equipped to Flourish take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel Equipped to Flourish has 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 hhs.gov/ocr/privacy/hipaa/complaints/.
- Equipped to Flourish will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what Equipped to Flourish share. If you have a clear preference for how Equipped to Flourish share your information in the situations described below, talk to us. Tell us what you want us to do, and Equipped to Flourish 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
If you are not able to tell us your preference, for example if you are unconscious, Equipped to Flourish may go ahead and share your information if Equipped to Flourish believe it is in your best interest. Equipped to Flourish may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, Equipped to Flourish never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising:
- Equipped to Flourish may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do Equipped to Flourish typically use or share your health information?
Equipped to Flourish typically use or share your health information in the following ways.
Treat you
Equipped to Flourish 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
Equipped to Flourish can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: Equipped to Flourish use health information about you to manage your treatment and services.
Bill for your services
Equipped to Flourish can use and share your health information to bill and get payment from health plans or other entities.
Example: Equipped to Flourish give information about you to your health insurance plan so it will pay for your services.
How else can Equipped to Flourish use or share your health information?
Equipped to Flourish 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. Equipped to Flourish have to meet many conditions in the law before Equipped to Flourish 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
Equipped to Flourish 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
Equipped to Flourish can use or share your information for health research.
Comply with the law
Equipped to Flourish 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 Equipped to Flourish is complying with federal privacy law.
Respond to organ and tissue donation requests
Equipped to Flourish can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
Equipped to Flourish 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
Equipped to Flourish can use or share health information about you:
- 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
Equipped to Flourish can share health information about you in response to a court or administrative order, or in response to a subpoena.
Our Responsibilities
- Equipped to Flourish are required by law to maintain the privacy and security of your protected health information.
- Equipped to Flourish will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- Equipped to Flourish must follow the duties and privacy practices described in this notice and give you a copy of it.
- Equipped to Flourish will not use or share your information other than as described here unless you tell us Equipped to Flourish can in writing. If you tell us Equipped to Flourish 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
Equipped to Flourish can change the terms of this notice, and the changes will apply to all information Equipped to Flourish has about you. The new notice will be available upon request, in our office, and on our Equipped to Flourish site.
Other Instructions for Notice
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Effective Data April 1, 2023
- For any questions contact David Hale at david@equippedtoflourish.com