HOLISTIC LACTATION LLC

MEMBER AGREEMENT

Definitions and Purpose

Definitions: 

  • “Holistic Lactation” and the pronouns “we” and “our” refer to Holistic Lactation LLC.

  • “Member” refers to the parent or guardian responsible for payment for services. 

  • “Patient” refers to a parent listed on the patient intake form, for whom Member seeks medical care, and for whom Holistic Lactation agrees to provide lactation services. 

  • “Primary Lactation Consultant” refers to the lactation consultant chosen by the Member to provide lactation services to the Patient

  • “Treating Lactation Consultant” refers to the lactation conasultant directly providing lactation services to the Patient. Except during periods of lactation consultant leave or emergencies, the treating lactation consultant will be the Patient’s Primary Lactation Consultant. 

Purpose:

•   This Membership Agreement delineates the terms of services provided by Holistic Lactation and is a legally binding contract between Holistic Lactation and the Member. 

 


Services

Services provided: 

Holistic Lactation provides comprehensive primary breastfeeding care to Patients of any age. These services include, but are not limited to newborn care, breastfeeding health maintenance exams, feeding assessments, problem-based visits, nutritional interventions within the typical scope of a lactation consultant, treatment of breast tissue damage, and other services deemed necessary and appropriate by the Treating Lactation Consultant. 

Holistic Lactation, through Treating Lactation Consultant, will render those services described in the Appendix to the Agreement (“Services”) to the patient or patients (each, a “Patient”) who pay the monthly membership fee.

The term of this Agreement will be one month commencing on the Effective Date and will continue from month-to-month thereafter unless terminated by either Member or Holistic Lactation. 

Limitations to service: 

Holistic Lactation membership is not health insurance, and any services that are not provided directly by Holistic Lactation are specifically excluded from the terms of this Membership Agreement and are not covered by the Membership Fee (defined below). The following is a non-exhaustive list of services that are excluded from the terms of this Membership Agreement: in person consultations, phone consultations, emergency services, hospitalizations, care provided by specialists to whom Holistic Lactation refers, medical imaging, laboratory services performed outside our office, and prescription medications. 

Location of services: 

Holistic Lactation provides services remotely and all correspondence is sent through a HIPAA-secure portal.

Timing of RESPONSES: 

Messages will be answered during Regular Business Hours (Monday-Friday from 9:00 am to 6 pm; subject to change).

Lactation Consultant availability: 

Holistic Lactation will provide direct access to the Member’s Primary Lactation Consultant. Members may contact Primary Lactation Consultant directly by email through the Patient Portal, as outlined in the communication protocol (see appendix). Messages will be returned as soon as practicable, typically same day on business days. Any work forms, Family Medical Leave Act forms, or other similar documents will be completed and returned by email or fax, or available for pickup in our office, within 2 business days of the request. 

While we make every effort to be available to our members, disruptions in infrastructure (such as prolonged power outage, a natural disaster, or disruption of cellular phone service) may render this impossible. Holistic Lactation is not responsible for costs, delays in care, or other harm occurring as a result of the failure of electrical or communication infrastructure or other systems that are beyond our control. 

Member hereby agrees that Holistic Lactation will not be liable for any failure to provide lactation services hereunder in the event that Treating Lactation consultant or any lactation consultant employed or under contract with Holistic Lactation are assisting other patients, are in an emergency situation, are out of town, or unable to make contact due to telecommunication failure or transportation failure, or due to other circumstances beyond the reasonable control of Holistic Lactation or its lactation consultants.


Fees and Payment Policies

Registration Fee: 

A registration fee of $27 per family is due at time of enrollment. 

Membership Fee: 

The Membership Fee provides access to the services offered by Holistic Lactation as described herein. The Membership Fee is billed monthly. Payments must be made via a credit card on file. 

Unless a different fee is agreed to in writing by Member and Holistic Lactation, Member agrees to pay Holistic Lactation a membership fee (the “Membership Fee”) based on the following schedule: 

Holistic Lactation Care

Monthly support membership fee: $27

The Membership Fee, and all other charges under this Agreement, may be changed by Holistic Lactation upon 30 days’ written notice; provided, however, no change may occur during the first 12 months of the term of the Agreement. 

The Membership Fees, and all other charges under this Agreement, will be paid by Member using the Stripe online solution, in which Member has enrolled. 

For services provided by Holistic Lactation for which there is an additional charge, Holistic Lactation shall establish a fee for service rate schedule (see appendix) that will be made available to Member, which may be amended from time to time at the sole discretion of Holistic Lactation. 

Non-payment: 

If the Membership Fee is not received by the due date, services will continue to be available for 30 days at a cost based upon the non-member rate. 

If payment is subsequently received within this 30-day period, services will resume without restriction on the date of payment, but this will not alter the due date for subsequent payments. If the Membership Fee is not received within 30 days of due date, the Member’s account will be closed, all Patient’s on the Member’s account will be discharged from the practice, this Membership Agreement will be terminated, and Holistic Lactation will assist with transfer of care to another lactation consultant.


Insurance

Participation in Insurance: 

Holistic Lactation does contract with, submit claims to, accept payments from, or otherwise engage with commercial companies or government payers. However, this benefit is not applicable to the Membership program. Members are strongly encouraged to maintain insurance coverage to cover medical services not provided by Holistic Lactation Some services provided by Holistic Lactation may be reimbursable by the Member’s insurance company as services rendered by an out-of-network provider or an in-network provider; Holistic Lactation cannot guarantee this reimbursement. Upon request, the Treating Lactation Consultant will provide to the Member necessary documentation for the visit and any procedures performed in a timely manner. 

Holistic Lactation does not make any representations whatsoever that any fees paid under this Agreement are covered by Member’s health insurance or other third party payment plans applicable to Member and/or Patient. Member shall retain full and complete responsibility for any such determination. 

Insurance or Other Medical Coverage.  

Member acknowledges and understands that this Agreement is not an insurance plan, and not a substitute for health insurance or other health plan coverage. It will not cover hospital services, any services not personally provided by Holistic Lactation or Treating Lactation Consultant, or any service not specifically set forth in this Agreement. Member acknowledges that Holistic Lactation has advised that Member obtain or keep in full force such health insurance policies or plans that will cover Patient for general healthcare costs. Member acknowledges that this Agreement is not a contract that provides health insurance and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Member may carry for the benefit of Patient. 


Other Topics

Commitment: 

Member understands that they are making a 1-month commitment. Member is responsible for the payment of the full 1-month period and any fees paid are non-refundable. 

Discontinuation of services refund of Membership Fee: 

In the event that an unforeseen circumstance subject to the reasonable discretion of Holistic Lactation (such as a death in the immediate family, or a significant change in the Member’s employment status) necessitating discontinuation of service, the remaining portion of the Membership Fee will be refunded after deducing the cost of services already provided. In this case, the non-member service rate will be used to calculate the cost of services already provided. 

Members who choose not to continue service with Holistic Lactation for other reasons must notify Holistic Lactation at least 30 days prior to the next Membership Fee due date. If Member is beyond the 1-month commitment period, they will be entitled to a prorated refund of the Membership fee, based on the number of days following termination for which Member has paid. 

Holistic Lactation does not discriminate against Members or Patients on the basis of race, color, ethnicity, age, religion, national origin, pregnancy, sexual orientation, gender identity, sex, marital status, or disability. However, Holistic Lactation reserves the right to discontinue services in cases of inappropriate interactions or safety concerns. In these cases, the Membership Fee will be refunded after deducing the cost of service already provided as described in the non-member rate. 

Communications: 

Communication via ChARM EHR, a HIPAA-compliant platform is our primary and preferred means of communication. Member acknowledges other forms of electronic communications, including without limitation, e-mail, video chat, messaging, and cell phone with Holistic Lactation and Treating Lactation Consultant are not secure or confidential methods of communication. As such, Member expressly waives any obligation of Holistic Lactation and Treating Lactation Consultant to guarantee confidentiality with respect to correspondence using such means of communication. Member acknowledges that all such communications may become part of Patient’s health records. By providing Member’s email address, Member authorizes Holistic Lactation and Treating Lactation Consultant to communicate with Member by email regarding Patient’s personal health information. Member acknowledges that: 

Email is not a secure medium for sending or receiving personal health information and a third party may have access;

Although Holistic Lactation and Treating Lactation Consultant will make all reasonable efforts to keep email communications confidential and secure, neither Holistic Lactation nor Treating Lactation Consultant can assure or guarantee confidentiality of email communications; 

At the discretion of Holistic Lactation or Treating Lactation Consultant, email communications may be part of the Patient’s permanent health record; and, 

Member understands and agrees that ChARM EHR or email are not appropriate means of communication regarding emergency or other time-sensitive issues. In the event of an emergency, or a situation in which the Patient could reasonably expect to develop into an emergency, Member shall call 911 or the nearest emergency room and follow the directions of the emergency personnel. If Member does not receive a response to a message, Member agrees to use another means of communication to contact Holistic Lactation or Treating Lactation Consultant. Neither Holistic Lactation nor Treating Lactation Consultant will be liable to Member or Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Member.


HIPAA

Member acknowledges that Holistic Lactation is a “covered entity” as defined in the Health Information Portability and Accountability Act, as amended (“HIPAA”), and as such, Holistic Lactation is subject to and is required to comply with HIPAA.

Specialist referrals and hospitalizations: 

Occasionally, a Patient’s condition warrants evaluation in person, in an emergency room, hospital admission, or referral to a specialist. In these cases, the Treating Lactation Consultant will make arrangements for treating or transferring care in a timely and professional manner. The Primary Lactation Consultant will communicate directly with the physician or team caring for the Patient, remain available for any questions from the family or the care team, and arrange any follow-up services required. The Primary Lactation Consultant will avoid interfering with the care team’s management. 

Emergency care: 

In the event of an emergency that is immediately threatening to the Patient’s life, limbs, or eyesight, the Member should call 911 or take the Patient directly to the nearest emergency room. The Member should notify Holistic Lactation as soon as practical. 

For situations that do not demand immediate emergency room management, the Member should contact Holistic Lactation as soon as possible to schedule an urgent visit or for guidance as to whether emergency room or hospital services may be required. 

Lactation Consultant leave: 

During the course of a calendar year, Holistic Lactation lactation consultants may take up to 45 days of leave for continuing education, medical treatment, or personal vacation. Except in the case of personal or family emergencies, Members will be notified of these periods at least 7 days in advance, and visits will be scheduled around these periods. Depending on the nature of the leave, the Primary Lactation Consultant may or may not be available for communication during these times. Arrangements for urgent visits during these periods will be made in advance by Holistic Lactation and will be performed either by another Holistic Lactation lactation consultant or referral to another trusted lactation consultant. 

Choice of lactation consultant: 

Members will choose a Primary Lactation Consultant at the time services are initiated. If at any time, there is another Holistic Lactation lactation consultant currently accepting new Patients, and a Member wishes to transfer care to another Primary Lactation Consultant for any reason, they may do so with the approval of the new Primary Lactation Consultant. 

Transfer of care: 

If, for any reason, service is discontinued, Holistic Lactation will assist the Member in arranging timely and appropriate transfer of care to another lactation consultant. 

Re-enrollment:

If, for any reason, services are discontinued, and the Member subsequently wishes to reenroll, a new Membership Agreement and registration fee will be required. Reenrollment will be at the discretion of Holistic Lactation. If there is a wait-list for services at that time, the Patient will be placed on this list. 

Reimbursement for Services Rendered: 

If this agreement is held to be invalid for any reason and Holistic Lactation is required to refund all or any portion of the Membership Fees that have been paid by Member, then Member agrees to pay Holistic Lactation an amount equal to the non-member rate for Services actually rendered to each Patient during the period of time for which the Fee is required to be refunded. 

Amendment:  

No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, Holistic Lactation may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending Member advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by Holistic Lactation. Moreover, if Applicable Law required this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been expressly set forth in this Agreement. 

Assignment: 

This Agreement, and any rights Member or Patient may have under it may not be assigned or transferred by Member or Patient. 

Legal Significance:

Member acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Member also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement. 

Miscellaneous:

This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or quality the text. 

If there is a change of any law, regulation or rule, federal, state or local, which affects this Agreement or the activities of either party under this Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that change will have a substantial adverse effect on the party’s rights, obligations or operations associated with this Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of this Agreement. If the parties are unable to reach an agreement concerning modification of this Agreement then either party may immediately terminate this Agreement by written notice to the other party. 

Entire Agreement:

This Agreement contains the entire agreement between the parties and supersedes all prior oral or written understandings and agreements regarding the subject matter of this Agreement. 

Jurisdiction:

This Agreement shall be governed and construed under the laws of the State of Arizona and all disputes arising out of this Agreement shall be settled by arbitration within proper venue and jurisdiction for Holistic Lactation address in Phoenix Arizona.  

Service:

All written notices are deemed serviced if sent by regular U.S. mail, to Holistic Lactation at the address listed above in this Agreement, and to Member at the address, which Holistic Lactation has on file. 

Authorization: 

By signing this Agreement, Member authorizes Holistic Lactation, Lactation Consultants, and Holistic Lactation staff, employees, agents and representatives: 

  1. to share confidential personal health information of each Patient with other treating physicians, hospitals, health care facilities and licensed health care practitioners for the purpose of performing Holistic Lactation obligations under this Agreement; and 

  1. to release any mental health, substance abuse, genetic information and HIV/AIDS information contained in each Patient’s personal health information as authorized by Applicable Law; provided, however, that if required by Applicable Law Holistic Lactation shall first obtain the separate written consent of Member or, if the Patient is 18 years of age or older, of Patient, prior to releasing any such mental health, substance abuse, genetic information and HIV/AIDS information. 

Member acknowledges that in accordance with Title 12, Article 7.1 of the Arizona Revised Statutes, each of Holistic Lactation, Lactation Consultant, and Holistic Lactation staff, employees, agents and representatives are authorized to share confidential personal health information for each Patient, including the nature or details of services provided to a Patient, with the following: 

  1. the Patient, or the individual making treatment decisions if the Patient is incapable to make decisions regarding health services provided; 

  1. for treatment, payment, or health care operations, in accordance with A.R.S. §§ 12-2293, 12-2294, and 12-2294.01;

  1. to those parties responsible for peer review, utilization review, and quality assurance, and 

  1. to those parties required to be notified under the Arizona Criminal Code ARS §13-3620.A

Holistic Lactation policies and practices governing its use and disclosure of personal health information are available to you upon request, and such policies and practices may be changed as necessary by Holistic Lactation as contained therein. Member may revoke this authorization at any time by providing written notice to Holistic Lactation via hand delivery at the address first listed above. However, if Holistic Lactation has taken any action in reliance on Member’s previously unrevoked authorization, Member’s revocation of this authorization shall not apply to such previous actions taken by Holistic Lactation. 

Member and Holistic Lactation have executed this Agreement as of the date of signature by each party. 


APPENDIX

Services

Services covered by the Member Agreement 

  • Lactation advice. Written guidance on resolving minor problems related to breastfeeding. lactation, and infant feeding.

  • Care coordination. Work with other members of Patient’s healthcare team to optimize Patient’s care. 


Service                                                            Member                                             Non-Member

House Call                                                        Based on geographic location           Based on geographic location

Initial Lactation Visit                                        $195                                                     $195

Follow Up Phone Consult                                $1.50/ min                                            $1.50/min

Pump Check                                                      $50                                                      $50

Phone/video/email communication                 Email included in membership          $50

Infant weight check                                          $25                                                       $25

Prenatal lactation consultation                        $150                                                     $150

Postnatal lactation consultation                       $195                                                     $195

Lactation follow-up                                           $95                                                       $125

Prenatal/postnatal consultation package         $350                                                     $400

Unlimited lactation support                              $400 monthly                                     $450 monthly

Lactation visits involving twins                         Included in membership                    +$50

Fee-for-Service Schedule