Grounded Lactation Appointment Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

After you fill out this order form, Grounded Lactation will contact you to determine an appointment time.

Email *

Do you have insurance? If you have not filled out The Lactation Network link for an insurance-covered appointment, please do so before filling out this form. *

Yes, I have insurance and have been approved by The Lactation Network

Yes, I have insurance and am waiting response from The Lactation Network

Yes, I have insurance, but The Lactation Network has responded and does not cover my insurance.

No, I am a self-pay client.

What type of appointment are you requesting? *

please note: home visits are within a 15 mile radius of downtown Durham. Includes much of Chapel Hill, Hillsborough, and Morrisville. $25 charge/visit for any visits outside of this range.

Prenatal Home Visit

Prenatal Televisit

Post Birth Parent & Baby Home Visit

Post Birth Mom only Home visit (for NICU moms)

In-office Visit at Holman Family Dental (1836 M.L.K. Jr Blvd, Chapel Hill, NC 27514)

Prenatal appointments are about 1 hour.

Post birth appointments are about 1.5-2hrs

Follow up appointments are about 1-1.5 hrs.

*In-office visits at Holman Family dental happen at end of clinic day on Mondays around 3pm or on evenings/weekends only.

Please list at least 3 dates and times you have available for your visit.

Visit Costs

Insurance (in-network) clients (BCBS, Anthem, Cigna PPO, Aetna, United, etc): Free! Up to 7 visits

The Lactation Network will submit all claims directly to your insurance company on behalf of Grounded Lactation. The Lactation Network will appeal all cost-sharing under the Affordable Care Act which states that lactation services are preventive and not subject to cost-sharing. You will not be billed for these visits.

Self-pay (out-of-network) clients: $200 initial; $150 follow-up

For out of network visits, you will be provided with a superbill with all the information you need to seek reimbursement from your insurance company and will serve as a payment receipt. You agree to pay me at the time of the visit (cash, check, credit card, FSA).

Cancellation Fee: $100

Any appointment not cancelled within 12 hours of appointment time. Notice via email is sufficient.

Outside Home Visit Radius: $25/visit

Any home visit outside of my 15 mile home radius is subject to a $25/visit charge. This is required at time of visit and is not covered by insurance. Please refer to groundlactation.com homepage for radius map.

Contact info

Your name *

Phone number *

E-mail *

Preferred contact method

Phone

Address *

Questions and Comments

*only include questions related to scheduling. You will receive an intake form prior to your appointment.

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of groundedlactation.com. Report Abuse

Forms