This is form will permit certain uses and disclosures of your protected health information. Please read it carefully. *

By clicking “Accept” below, I request and authorize the health care providers participating in the Lawrence Lactancia Collaborative through Doulas of the Diaspora (the “Disclosing Parties”) to share my protected health information (or “PHI”) as described in this form, with one another. The purpose of this Authorization is to enable the Disclosing Parties to share information about me as necessary to arrange for doula services, and to communicate with one another regarding those services, including monitoring the progress and the quality of those services. I understand that I may revoke this Authorization at any time, except to the extent that the Disclosing Parties have already taken action in reliance on it. My revocation will prevent future uses and disclosures of my PHI that aren’t otherwise permitted by law. I may revoke this Authorization by writing to: contact@doulasofthediaspora.org I understand that I am not required to accept this Authorization and that my refusal to accept will not affect my eligibility for treatment or other benefits to which I am otherwise entitled. However, if I refuse to sign this Authorization, I may not receive all of the benefits of participation in the Lawrence Lactancia Collaborative. I understand that PHI disclosed to certain third parties under this Authorization may be subject to redisclosure if those parties are not obligated to comply with HIPAA. This Authorization will expire at the end of my participation in the Lawrence Lactancia Collaborative. I understand that clicking the “Accept” button below is the electronic equivalent of my signature and will permit the Disclosing Parties to use and disclose my PHI as described in this form.

I agree

Client Name *

Nombre de la cliente

First Name

Last Name

Date of Birth *

Fecha de nacimiento

MM

DD

YYYY

Phone *

Número de teléfono

Country

(###)

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Home Address *

Dirreción de casa

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Due Date or Delivery Date *

If the client has already delivered, enter delivery date. | Fecha probable del parto; si la cliente ya dio a luz, escriba la fecha del parto.

MM

DD

YYYY

Client Concerns *

Preocupaciones de la cliente

Latching | Asegurando/chupado del bebé

Frequency | Frecuencia

Pumping | Extracción de leche materna

Supply | Quantidad de leche

Infant Growth | Crescemiento del bebé

Breast Discomfort | Malestar mamario

Other | Otra preocupación

Referral Submitted By *

Your name (name of the person completing this referral on behalf of the client). | Su nombre (nombre de la persona llenando esta applicación).

First Name

Last Name

Phone

Número de teléfono

(###)

###

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