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..

  • 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.

  • Equipment:. I agree to exercise reasonable care while using the equipment and acknowledge responsibility for any damage to the phototherapy bed or related equipment caused by negligence, misuse, intentional acts, unauthorized alterations, or failure to follow instructions provided.  In the event of such damage, I agree to reimburse the provider for the reasonable cost of repair or replacement, up to the fair market replacement value of the equipment, not to exceed $5,000, excluding ordinary wear and tear or equipment malfunction.

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: ________________

Please note that the provider and the parent will examine the phototherapy bed and a photo will be 

taken to record the phototherapy bed’s condition prior to the start of the treatment.