mysticmomma
03-13-2006, 12:22 PM
This is what I have so far. Is it to wordy? Long? Missing anything? I want to put something about confidentiality on their part and my part... but cant figure out how to word it. Help!
I give my permission, for Motherload Personal Services to take notes about me, including personal information I choose to disclose to her, and information regarding my labor, birth and postpartum, as well as any information
regarding my child/ren. I understand that this information may be used for the
purpose of doula certification or recertification. I realize that this information will be shared with the doula that is providing back up support. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations.
We the undersigned, do hereby give our consent and authorize and permit MOTHERLOAD PERSONAL SERVICES to use or permit other persons to use the negatives, photographic prints, digital images, slides and or video prepared there from, for such purposes and in any such manner as they choose without any compensation or recognition of any kind to those photographs. These negatives, prints, digital images, etc. are the sole property of MOTHERLOAD PERSONAL SERVICES. MOTHERLOAD PERSONAL SERVICES agrees to allow clients the opportunity to view images prior to publishing. Clients will be allowed to indicate below any image numbers they do not permit to be published. Clients will also be given a complete set of images for their own personal use.
We understand that Motherload Personal Services in their capacity as labor doulas or lactation educators are NOT medical professionals and cannot offer medical advice, diagnose or treat medical conditions. Motherload Personal Services do not perform clinical tasks, offer second opinions or make decisions for our clients. The only role of Motherload Personal Services is to provide physical, emotional and informational support to women and their partners during labor, birth and the entire duration of the breastfeeding relationship.
I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS Motherload Personal Services, its respective administrators, members, directors, agents, officers, volunteers and employees from all liability, claims, demands, losses, or damages.
Optional: Please allow access to my personal health information (PHI) to:
__________________________________________________ ______________
Name Address Phone Number
__________________________________________________ ______________
Name Address Phone Number
__________________________________________________ ______________
Name Address Phone Number
__________________________________________________ ______________
Name Address Phone Number
I give my permission, for Motherload Personal Services to take notes about me, including personal information I choose to disclose to her, and information regarding my labor, birth and postpartum, as well as any information
regarding my child/ren. I understand that this information may be used for the
purpose of doula certification or recertification. I realize that this information will be shared with the doula that is providing back up support. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations.
We the undersigned, do hereby give our consent and authorize and permit MOTHERLOAD PERSONAL SERVICES to use or permit other persons to use the negatives, photographic prints, digital images, slides and or video prepared there from, for such purposes and in any such manner as they choose without any compensation or recognition of any kind to those photographs. These negatives, prints, digital images, etc. are the sole property of MOTHERLOAD PERSONAL SERVICES. MOTHERLOAD PERSONAL SERVICES agrees to allow clients the opportunity to view images prior to publishing. Clients will be allowed to indicate below any image numbers they do not permit to be published. Clients will also be given a complete set of images for their own personal use.
We understand that Motherload Personal Services in their capacity as labor doulas or lactation educators are NOT medical professionals and cannot offer medical advice, diagnose or treat medical conditions. Motherload Personal Services do not perform clinical tasks, offer second opinions or make decisions for our clients. The only role of Motherload Personal Services is to provide physical, emotional and informational support to women and their partners during labor, birth and the entire duration of the breastfeeding relationship.
I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD HARMLESS Motherload Personal Services, its respective administrators, members, directors, agents, officers, volunteers and employees from all liability, claims, demands, losses, or damages.
Optional: Please allow access to my personal health information (PHI) to:
__________________________________________________ ______________
Name Address Phone Number
__________________________________________________ ______________
Name Address Phone Number
__________________________________________________ ______________
Name Address Phone Number
__________________________________________________ ______________
Name Address Phone Number