Lactation Consultant & Feeding Template

Free Lactation Consultant & Infant Feeding Agreement Template

Generate an IBCLC and CLC feeding support agreement complete with clinical assessment terms, HIPAA confidentiality, and insurance superbill authorization.

Contract Specialty Preset:

1. Your Practice Details

Doula / Practice Name

Email Address

Phone (Optional)

City

State / Province

Logo Upload (Optional)

Choose Logo Image

2. Client / Family Information

Client Primary Name

Partner Name (Optional)

Client Email

Estimated Due Date

3. Financial & On-Call Terms

Agreement Title

Agreement Date

Total Fee

Retainer Deposit

Currency

On-Call Window Period

Payment Schedule & Milestones

4. Agreed Services & Deliverables

5. Contract Clauses & Policy Terms

6. Custom Provisions & Special Notes

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Download a clean PDF immediately or save your draft to collect legally-binding digital signatures.

Lactation Consultation & Infant Feeding Agreement

Effective Date: August 23, 2026

Service Contract

Blossom Birth Support

hello@blossombirth.com

Doula / Service Provider

Blossom Birth Support

Seattle, WA

hello@blossombirth.com

Client / Expectant Family

Elena Rostova & Liam Rostova

elena@example.com

Due Date: October 15, 2026

Total Agreed Fee

$250

Retainer Deposit

$100(Non-Refundable)

On-Call Window

Scheduled appointment basis

Scope of Services & Package Deliverables

Comprehensive in-home or clinic lactation assessment including oral anatomy evaluation, pre- and post-feed weighted scale measurements, latch and positioning optimization, personalized feeding plan, and 14 days of follow-up messaging.

Contract Terms & Legal Provisions

1. Scope of Lactation Care & Assessment

The Consultant provides clinical lactation and infant feeding evaluation. Consultations include maternal medical history review, breast anatomy examination, infant oral function assessment, weighted feed analysis, and an individualized care plan.

2. HIPAA Privacy & Medical Record Sharing Consent

The Client authorises the Consultant to share the lactation assessment and feeding plan with the Client's OB/GYN, Midwife, and Pediatrician to ensure coordinated perinatal medical care.

3. Insurance Superbill & Payment Responsibility

The Client is solely responsible for payment of all consultation fees. The Consultant will provide an itemized Superbill with relevant CPT and ICD-10 diagnostic codes for the Client to submit to their health insurance or HSA/FSA provider for reimbursement.

4. Follow-Up Support & Emergency Protocols

Consultation fee includes up to two (2) weeks of secure follow-up text/email messaging. For urgent medical concerns (e.g. high fever, severe mastitis, infant dehydration), the Client must contact their primary medical provider or emergency services immediately.

By executing this agreement, both parties confirm their mutual understanding and acceptance of all terms, policies, and non-medical limits.

Blossom Birth Support

[Signature Line]

Date: ________________________

Elena Rostova

[Signature Line]

Date: ________________________

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Expert Contract & Legal Tips for Lactation Consultant & Feedings

Best practices to protect your practice and set clear boundaries with clients.

Include Pediatrician Communication Consent

Always get written consent to send your lactation care plan to the baby's pediatrician. This establishes clinical credibility and protects continuity of care.

Clarify Superbill Reimbursement

Remind clients that payment is due upfront, and reimbursement by their insurer is between them and their insurance carrier.

Frequently Asked Legal & Contract Questions

Best practices for Lactation Consultation & Feeding Agreement managing contracts and client agreements.

Can lactation consultants provide insurance superbills?

Yes. An itemized superbill with CPT codes (e.g., S9445, 99402) and doula/IBCLC NPI number allows families to claim reimbursement under the ACA lactation mandate.

What is included in follow-up lactation messaging?

Most consultants include 1 to 2 weeks of follow-up messaging to answer quick questions and fine-tune feeding plans.

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