Healthcare Postpartum Package

HEALTHCARE POSTPARTUM PACKAGE

Patient Information

Date of Birth:    Gender:    Preferred Pronouns:

Primary Phone:    Secondary Phone:    Email:

Relationship:    Phone:

Insurance & Billing

Policy / ID Number:    Group Number:    Subscriber Name:

I acknowledge that I am financially responsible for services not covered by insurance and that the practice may bill insurance on my behalf. I understand fees, co-payments, and applicable balances are my responsibility under standard billing practices.
I acknowledge financial responsibility

Medical & Obstetric History

Current Obstetric Provider:    Pediatric Provider (if arranged):

Postpartum Package Components

Select the services included in this postpartum package (check all that apply):

In-home postpartum visit(s) Lactation consultation Mental health screening (depression/anxiety)

Pelvic floor assessment/therapy Newborn care and feeding support Contraceptive counseling

Total number of visits included:    Duration per visit:    Package Fee: $

Consent for Postpartum Care

I authorize the providers and staff associated with this postpartum package to perform assessments and provide clinical care, education, and counseling as described above. I understand that care may include physical assessment, lactation assistance, mental health screening, education on infant care, and referrals as clinically indicated.

I acknowledge that all clinical services carry potential benefits and risks. Potential risks may include temporary discomfort during physical assessment, skin irritation from topical preparations, and emotional responses to mental health screening. Benefits include improved maternal recovery, increased breastfeeding success, and earlier identification of complications. I have had an opportunity to ask questions and have received satisfactory answers.

I understand that I may revoke this consent at any time in writing, except to the extent that action has already been taken in reliance on it. Revocation does not affect disclosures already made based on this authorization.

I consent to clinical photographs/notes for my medical record I do not consent to clinical photographs

HIPAA & Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices describing how my health information may be used and disclosed. I understand my rights to inspect and obtain copies of my health information, request amendments, and request restrictions on certain uses and disclosures. I understand the practice will use and disclose protected health information for treatment, payment, and healthcare operations as necessary to provide care and process claims.

Authorization for disclosure: I authorize the practice to share relevant postpartum and infant care information with the following persons or providers (enter names and relationship). This authorization is limited to the scope necessary for continuity of care and may be revoked in writing at any time.

Authorization Expiration Date:

Clinical Screening & Follow-Up

Breastfeeding status:    Infant feeding concerns:

Screening result (to be completed by clinician):    Recommended follow-up:

Referrals & Coordination of Care

I consent to release of relevant postpartum health information to referring providers for coordination of care. This release is limited to information necessary for the referral and care coordination.
I consent to release information for referrals

Cancellation & No-Show Policy

Appointments cancelled with less than 24 hours' notice or missed without notification may incur a fee. I acknowledge that repeat cancellations or no-shows may result in discontinuation of scheduled package services and that outstanding balances remain my responsibility.
I acknowledge the cancellation and no-show policy

Patient Certifications

By signing below I certify that the information I have provided is true and complete to the best of my knowledge. I authorize the provision of postpartum services described in this package and consent to the uses and disclosures of my health information as stated herein. I understand that this document constitutes an agreement for the services and terms set forth above.

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