Consent for Treatment & Equipment Use


Patient Name: ________________________________DOB: _______________ 

Parent/Guardian: __________________________________________________

Scope of Services

I hereby consent to the following services provided by Lumi: Heal At Home Newborn Phototherapy

  • Home Phototherapy: Set-up and education on the use of Skylife Phototherapy system for the treatment of neonatal jaundice.

  • Lactation Consultation: Physical assessment of the breastfeeding parent and infant, observation of feeding, and clinical recommendations to improve milk transfer and supply.

Risks and Responsibilities

  • Phototherapy: I understand that while phototherapy is standard care, potential side effects include loose stools, skin rash, or dehydration. I agree to monitor my infant’s temperature, feedings, voiding and stooling as instructed.

  • Equipment: I assume responsibility for the proper handling of the phototherapy equipment and agree to notify the provider immediately if the device malfunctions.

  • Lactation: I understand that lactation recommendations are based on the information provided and that no specific outcome (e.g., "perfect latch") can be guaranteed.

  • Emergency Acknowledgment: I understand that if my infant becomes lethargic, refuses to feed, or shows increased jaundice, I must contact the pediatrician or seek emergency care immediately.




HIPAA Privacy & Disclosure


Notice of Privacy Practices

I acknowledge that I have been offered/provided a copy of the Notice of Privacy Practices, which explains how my health information may be used for treatment, payment, and healthcare operations.

Authorization for Communication

I authorize Lumi:  At Home Newborn Phototherapy to communicate PHI via the following (check all that apply):

  • [ ] Secure Email.  Email address:__________________________________________

  • [ ] Phone/Voicemail.  Phone:_____________________________________________

  • [ ] Collaboration: I authorize the provider to share treatment notes and bilirubin levels with my infant’s Pediatrician: ______________________________________________

Financial Agreement & Signature

  • Payment: Payment is due at the time of service unless otherwise arranged.

  • Insurance: I understand that Lumi:  Heal At Home Newborn Phototherapy                 (is or is not) an in-network provider. I am responsible for any fees not covered by my insurance.

Signature of Parent/Guardian: __________________________ Date: ________________

Printed Name: ______________________________________ 

Provider Signature ___________________________________  Date: ________________