1- CALIFORNIA STATE MANDATORY DISCLOSURE (SB 577)
NOTICE TO CONSUMER: California Senate Bill 577 (codified as Business and Professions Code Sections 2053.5 and 2053.6) allows the practice of alternative or complementary health services by unlicensed practitioners, provided specific disclosures are made.
I, Rafaela Schmidit Almeida, am an International Board Certified Lactation Consultant (IBCLC). In compliance with California law, I hereby disclose the following:
1.1- I am NOT a licensed physician. My services are NOT licensed by the State of California.
1.2- Nature of Services: I provide lactation consulting, which includes assessment of breastfeeding dynamics, educational guidance on positioning and latch, and support for lactation goals. These services are alternative or complementary to healing arts services licensed by the state.
1.3- Theory of Treatment: My practice is based on the clinical competencies and standards of practice defined by the International Board of Lactation Consultant Examiners (IBLCE). The focus is on the management of breastfeeding and human lactation through education, observation, and non-medical support.
1.4- Qualifications: I hold the credential of International Board Certified Lactation Consultant (IBCLC), Certification Number L-319356, valid through. My training includes.
2- CONSENT FOR CARE AND SCOPE OF SERVICES
I authorize Rafaela Schmidit Almeida to perform a lactation consultation. I understand that this service is educational, preventive, and supportive in nature and does not have a medical purpose. I understand that the Consultant does not diagnose medical conditions, prescribe medications, or perform invasive medical procedures.
The consultation may include:
- Assessment: visual and physical examination of the mother's breasts and the infant's oral anatomy
- Observation: watching a breastfeeding session to assess latch and milk transfer
- Technique: hands-on assistance (with permission) to adjust positioning and latch to improve comfort and efficacy.
- Education: use of props (dolls, videos) to demonstrate techniques.
- Documentation: recording of findings in a confidential client chart.
3- BENEFITS, RISKS, AND LIMITATIONS
- Benefits: Potential improvements in latch comfort, reduction of nipple trauma, management of engorgement, and increased confidence.
- Risks: there may be temporary discomfort during breast examinations or latch adjustments. Recommendations may not resolve all breastfeeding issues immediately.
- Limitation: this consultation is not a substitute for medical care. I understand that I should continue to consult with my pediatrician and obstetrician/midwife for any medical concerns regarding myself or my baby.
4- PRIVACY RIGHTS AND RELEASE OF INFORMATION (HIPAA/CMIA)
Your privacy is protected under federal (HIPAA) and California (CMIA) laws.
- Confidentiality: Your information will be kept confidential and secure.
- Coordination of Care: to ensure safety and continuity of care, it is standard practice to share consultation notes with your baby's pediatrician or your primary healthcare provider.
5- MANDATED REPORTING ACKNOWLEDGEMENT
I understand that while my Lactation Consultant protects my privacy, they are ethically (and potentially legally, depending on licensure status) obligated to report known or suspected incidents of child abuse or neglect to proper authorities, in accordance with California Penal Code § 11164 et seq.
6- FINANCIAL RESPONSIBILITY AND CANCELLATION
- Payment is due at the time of service or online using credit card.
- I understand that I am responsible for seeking reimbursement from my insurance company, and reimbursement is not guaranteed.
- Cancellation Policy: Notify at least 24 hours in advance. A late cancellation fee of $75 will be charged for notifications received less than 24 hours before the appointment time.
- Travel Fee: In-home consultations within Santa Clara County have no travel fee. A $50 travel fee applies for all other service areas listed below.
Service Area and Travel Fees
Santa Clara County (FREE Travel):
Campbell, Cupertino, Gilroy, Los Altos, Los Altos Hills, Los Gatos, Milpitas, Monte Sereno, Morgan Hill, Mountain View, Palo Alto, San Jose, Santa Clara, Saratoga, Sunnyvale.
Other Cities ($50 Travel Fee):
Alameda, Alamo, Albany, Alviso, Aptos, Aromas, Atherton, Belmont, Ben Lomond, Berkeley, Boulder Creek, Brisbane, Brookdale, Burlingame, Canyon, Capitola, Castro Valley, Coyote, Daly City, Danville, Diablo, Dublin, El Cerrito, El Granada, Emeryville, Felton, Fremont, Half Moon Bay, Hayward, Hollister, La Honda, Lafayette, Livermore, Loma Mar, Menlo Park, Millbrae, Montara, Moraga, Moss Beach, Mount Hamilton, Mount Hermon, Newark, Oakland, Orinda, Pacifica, Pescadero, Pittsburg, Pleasanton, Portola Valley, Redwood City, Richmond, San Bruno, San Carlos, San Francisco, San Gregorio, San Juan Bautista, San Leandro, San Lorenzo, San Martin, San Mateo, San Ramon, Santa Cruz, Sausalito, Scotts Valley, Soquel, South San Francisco, Stanford, Sunol, Tracy, Union City, Walnut Creek, Watsonville.
7- WAIVER OF LIABILITY
I voluntarily consent to this consultation. I hereby release and hold harmless Rafaela Schmidit Almeida from any and all liability, claims, or causes of action arising out of the educational and support services provided, except in cases of gross negligence or intentional misconduct. I assume the risk associated with following the recommendations provided.
8- CLIENT RIGHTS
I have the right to stop the consultation at any time. I have the right to be informed about all procedures.