Lactation Care Services and Telehealth Informed Consent

I am requesting lactation care and related services (the "Care Services") from Milk Wise Medical, P.C. and other associated medical practices (collectively, the "Medical Group"). I understand that the Care Services may be furnished by lactation consultants, physicians, and other personnel who are employed by or otherwise engaged with the Medical Group (as defined below)(each, a "Professional"), and that some Professionals are independent contractors rather than employees. This Lactation Care Services and Telehealth Informed Consent is referred to as this "Consent."

I understand that Milk Bar Collective, Inc. d/b/a MilkWise ("MilkWise") provides the technology platform and administrative business support to the Medical Group. MilkWise does not provide medical care and does not direct or control the clinical judgment of any physician or other licensed clinician of the Medical Group.

I understand that my Professional's credentials, license or certification type, and role will be identified to me, and that I may ask at any time who is providing my care and in what capacity.

I may contact the Medical Group at patients@milkwise.care with any concern or complaint about my care, including for information about how to file a complaint with the applicable state licensing or certification board.

I understand that a lactation consultation, whether in person or virtual, may include:

• Review of my pregnancy, birth, medical, and feeding history and my infant's history;
• Observation of a full or partial feeding, including latch, positioning, and milk transfer;
• Visual and hands-on assessment of my breasts, chest, and nipples, including palpation;
• Visual and digital oral assessment of my infant, including assessment of the tongue, lips, palate, and suck function;
• Weighing my infant before and after a feeding, including undressing my infant;
• Assistance with hand expression, pumping, flange fitting, supplemental feeding devices, nipple shields, and bottle feeding;
• Development of an individualized feeding and care plan, including follow-up recommendations; and
• Education, counseling, and referral to other providers where appropriate.

I understand that in-person lactation care involves physical touch of me and my infant, and I consent to that touch as part of the assessment and care described above. I may decline any portion of the assessment at any time, and I may ask the Professional to stop at any time.

I understand that:

• Lactation care is not a substitute for medical care for me or my infant. All medical diagnosis and treatment must be provided by a licensed physician or other appropriately licensed clinician;
• My Professional will not diagnose or treat medical conditions outside the scope of that Professional's license, certification, and training, and will refer me to my physician, my infant's pediatrician, or another appropriate provider when care falls outside that scope;
• Responsibility for my overall medical care and my infant's overall medical care remains with my own providers, and I am encouraged to maintain a relationship with an obstetric provider and a pediatrician;
• No particular outcome, milk supply, weight gain, feeding result, or resolution of a feeding difficulty can be guaranteed; and
• It is my responsibility to follow the care plan, to evaluate how it is working for me and my infant, and to contact my Professional, my physician, or my infant's pediatrician if my condition or my infant's condition changes or does not improve.

Care Services, including telehealth visits and messaging, are not for emergencies. If I believe my infant is not feeding adequately, is dehydrated, is lethargic, is losing weight, or is otherwise unwell, or if I have signs of infection such as fever, or if I am experiencing thoughts of harming myself or my baby, I will contact my physician or my infant's pediatrician immediately, call 911, or go to the nearest emergency department. For a mental health crisis, I may call or text 988.

I authorize the Medical Group to send information about my consultations, including my care plan, visit notes, assessments, and recommendations, to my obstetric provider, my infant's pediatrician, my primary care provider, and other health care providers involved in my care or my infant's care, for treatment, payment, and health care operations purposes. I understand I may ask that this not be done by contacting patients@milkwise.care, and that declining may affect care coordination and insurance coverage.

I understand that I may choose to have another person present during my visit, and that anyone present will have access to my health information and my infant's health information. The Medical Group is not responsible for any disclosure by a person I invite to be present, or by a person I add to a text or email thread.

I understand that photographs or video of me or my infant will not be taken for clinical documentation, education, training, research, or marketing purposes without my separate written authorization, which I may revoke at any time. My identifiable images and information from any visit, including a telehealth visit, will not be shared with researchers or other educational entities without my separate written authorization.

The Medical Group and MilkWise use artificial intelligence and machine learning tools (“AI Tools”) in the operation of the Medical Group. We are telling you this so that you know when AI is involved in your care and can make an informed choice about it. AI Tools may be used for the following purposes:

a. Listening to or reading a visit and drafting a clinical note, summary, or transcript for your Professional to review, edit, and approve.

b. Scheduling, registration, eligibility checks, coding support, billing, claims, call routing, staffing, and other clerical matters.

c. Drafting appointment reminders, educational material, and responses to routine non-clinical messages.

d. Surfacing information, flagging possible risks or gaps in care, summarizing records, and suggesting options for a Professional to consider.

e. Population health, quality measurement, utilization review, and program improvement.

AI Tools do not practice medicine. AI Tools do not diagnose you, do not prescribe or order treatment, do not deny or limit care, do not provide therapy or counseling, and do not make clinical decisions about your care. Every diagnosis, prescription, order, and treatment decision is made by a human Professional exercising independent professional judgment.

You may always request to speak with a human. Contact us at 323-673-2517 or patients@milkwise.care or ask your Professional directly.

You may ask us not to use AI Tools in connection with your care by contacting us at patients@milkwise.care. Declining will not cause you to be denied care, though it may limit the availability of certain conveniences or features, and we will discuss the practical effects with you.

I understand that Professionals are mandatory reporters under applicable state law and are required to report suspected abuse, neglect, or endangerment of a child or other vulnerable person to the appropriate authorities, and that this obligation may require disclosure of my information without my consent.

Telehealth is the delivery of health care services using electronic communications between a patient and a Professional who are in different locations. My telehealth visit with the Medical Group may involve live two-way audio and video, telephone, secure messaging, photographs or video I submit, shared documents, and review of my health records.

Benefits of telehealth include access to lactation care from my home, faster access to a Professional, reduced travel with a newborn, and access to Professionals who may not be available locally.

Risks and limitations of telehealth include:

• Delays or interruptions caused by technology or equipment failure;
• Image, video, or audio quality that is inadequate for assessment, which may require the visit to be rescheduled or converted to an in-person visit;
• The inability to perform hands-on assessment, including palpation of the breast or chest, digital oral assessment of my infant, and pre- and post-feeding weights, which may limit what my Professional can evaluate;
• Incomplete or inaccurate information, which may lead to errors in judgment or recommendations that are not appropriate for my situation; and
• Rare security failures or interception of transmitted information, resulting in a breach of privacy.

My Professional will determine whether my needs and my infant's needs can be appropriately addressed by telehealth. If they cannot, I will be told and will be assisted in arranging an in-person visit with the Medical Group where available, or referred to my physician, my infant's pediatrician, or another appropriate provider.

When a Professional is available to me, I will be connected with one who is authorized to furnish the applicable services in the state where I am physically located at the time of the visit. I agree to tell my Professional where I am located at the start of each visit and to notify the Medical Group if my location changes.

I understand that in-person alternatives to telehealth may be offered to me, including in-home and in-office visits, depending on my Professional and whether in-person visits are available in my area, and that I may request an in-person visit instead of telehealth.

Records of my telehealth visits are created and maintained by the Medical Group on the same basis as in-person visits, and I may request copies. My primary care provider, my obstetric provider, and my infant's pediatrician may obtain a copy of the records of my telehealth encounter.

Persons other than my Professional may be present during a telehealth visit for technical or administrative reasons. I will be informed of their presence, I may ask non-clinical personnel to leave, I may omit personally sensitive details, and I may end the visit at any time.

If I cannot reach my Professional through the Platform (as defined in Section 13) because of a technology or equipment failure, I may contact the Medical Group at 323-673-2517 or patients@milkwise.care.

Medical doctors are licensed and regulated by the Medical Board of California, (800) 633-2322, www.mbc.ca.gov.

I am responsible for paying all fees for Care Services furnished by the Medical Group, including any copayments, coinsurance, deductibles, and amounts not covered by my health plan (the "Fees"). Fees are due at the time of service or upon receipt of an invoice.

By providing my credit card or other payment information, I authorize the Medical Group, and MilkWise on the Medical Group's behalf, to store that information and charge it for Fees for Care Services I request, without additional consent.

a. Your financial responsibility. If you pay for services without insurance, or if your health insurance (including Medicare) does not cover the charges for your services in full or at all, you shall be responsible for payment of all amounts invoiced to you. If your health plan requires you to pay a deductible, copayment, or coinsurance, the usual cost-sharing rules will apply. You are responsible for paying us for services we provide that are not paid by your insurer or other third parties, unless applicable state or federal law does not allow this. If you request, we will work with you to estimate your charges, and if you pay without insurance, we will inform you of any amounts owed.

b. No representation regarding coverage. The Medical Group makes no representation that any service is or is not covered by your health insurance or any other third-party payment plan. Please check with your health plan to determine whether a service will be reimbursed. Submitting charges to your insurer or another third party does not waive our right to seek payment directly from you, subject to applicable law.

c. Authorization to submit claims and release information. If you provide information about your health insurance or another third-party payment plan, you authorize the Medical Group to submit claims on your behalf for covered services. You authorize the release of information necessary to process your claims.

d. Assignment of benefits. You assign to the Medical Group all right, title, and interest in any health insurance or other health care benefits payable to you or on your behalf for services rendered by the Medical Group and its Professionals. You authorize Medicare, your health plan, and any other third party responsible for any part of your bill to pay those amounts directly to the Medical Group instead of to you. This assignment remains in effect until you revoke it in writing.

e. Payments made directly to you. If an insurer or other third party pays you directly for services provided by the Medical Group, you agree to promptly pay those amounts to the Medical Group.

f. Referrals. If my health plan requires a referral or prior authorization for a service, I am responsible for obtaining the referral or prior authorization before my appointment, and I may be responsible for charges that my plan denies because a required referral or prior authorization was not obtained.

g. Collection costs. To the extent permitted by applicable law, if collection action is necessary to collect amounts you owe to the Medical Group, you agree to pay the reasonable costs of that action, including collection agency fees and attorneys’ fees.

h. Payment methods. We accept credit and debit cards issued by U.S. banks and other payment methods identified on the Platform. If you choose to pay by card, we may obtain preapproval for an amount up to the amount of the payment. If you enroll in recurring automatic payments, charges will be billed to the card you designate, and you may revoke that authorization at any time by updating your payment settings on the Platform or contacting us at patients@milkwise.care. If your card information changes, you must update it on the Platform, which may briefly delay payment processing while we verify the new information. Keeping a card on file or agreeing to card preapproval is optional and is not a condition of receiving Care Services.

If I need to reschedule or cancel an appointment, I will notify the Medical Group at least 24 hours in advance. If I repeatedly miss appointments and cannot be reached for a significant period of time, the Medical Group may discharge me from care after notice to me.

The Medical Group's use and disclosure of my health information and my infant's health information is described in its Notice of Privacy Practices and the MilkWise Privacy Policy, and I acknowledge receipt of the Notice of Privacy Practices. I understand that my information may be shared with MilkWise and its personnel and vendors for scheduling, billing, and other administrative purposes.

The Medical Group and MilkWise use a secure online platform (the "Platform") to maintain my health information and my infant's health information and to support visits, messaging, scheduling, billing, and document sharing. Access to the Platform by Professionals and MilkWise personnel is limited to authorized treatment, payment, health care operations, and other purposes permitted by law, and Platform activity is logged and may be monitored and audited.

My Platform login credentials are for my use only. I will keep them confidential, will not share them with anyone, and will promptly notify privacy@milkwise.care if I believe my account has been lost, stolen, or accessed without my permission. I understand that anyone I allow to use my account or device may be able to see my health information and my infant's health information.

Photographs, videos, and documents I upload to the Platform will become part of my health record, and I am responsible for making sure that what I upload is accurate and relates to me or my infant.

Text Messages and Email

By providing my phone number and email address, I consent to receive text messages and emails from the Medical Group and MilkWise related to my Care Services, such as appointment reminders and follow-up communications. Text messages and email are not always secure, message frequency may vary, and message and data rates may apply. This consent is not required to receive Care Services, and I may opt out at any time by contacting privacy@milkwise.care or replying STOP.

I may withdraw this consent, including my consent to telehealth, decline any recommended service, or discontinue care at any time without affecting my right to future care. Withdrawal is effective when received and does not affect anything already done in reliance on the consent.

I have read this Consent, including the telehealth terms in Section 8, I have had the opportunity to ask questions, and my questions have been answered. I understand that the Medical Group will rely on the information I provide as accurate and complete, and that inaccurate or incomplete information may affect my care. I consent to receive Care Services, including by telehealth, from the Medical Group and its Professionals for myself and, as applicable, for my infant or child, as the parent or legal guardian authorized to consent on the child's behalf.

By clicking “I agree” to this Consent, I agree that the Medical Group may share my health information and my infant's health information, without further notice to me, while I am receiving Care Services from the Medical Group, as follows:

With my other health care providers, including my obstetric provider, my infant's pediatrician, and my primary care provider, directly or through the Medical Group's participation in health information exchanges, for treatment, payment, health care operations, and care coordination purposes, as described in Section 4. In most instances, the Medical Group will send my visit records to my primary care provider and my infant's pediatrician after each visit;

With other individuals involved in my care or my infant's care, such as caregivers or family members, unless I object;

With my health plan, directly or through health information exchanges, for payment, care coordination, health care operations, and treatment purposes, such as eligibility verification, claims processing, and audits of the Medical Group's services; and as otherwise permitted by the Medical Group's Notice of Privacy Practices and applicable law.

Information that receives special protection under California or federal law, such as HIV test results, mental health information, substance use disorder information, and genetic test information, will be used and disclosed only as permitted by that law, and the Medical Group will request my separate written authorization where the law requires it.