Hospital Grade Breast Pump Rental Agreement

  1. Customer Agreement
  2. Hours of Availability
  3. Instructions for Set-Up of Durable Medical Equipment
  4. Safety Precautions
  5. Emergency or Natural Disaster
  6. Customer Suggestions or Complaints
  7. Customer Bill of Rights and Responsibilities
  8. HIPAA Notice of Information/Privacy Practices
  9. DME Supplier Standards
  10. Community Resources

SECTION ONE: Customer Agreement

  • I hereby authorize Acelleron to charge my credit card (plus tax if applicable) for the rental period and accessories selected on this form.
  • I understand that Acelleron is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
  • I certify that I have been provided the Hours of Availability, Instructions for Set-Up of HME, Safety Precautions, Emergency or Natural Disaster Information, Customer Complaint Policy, Customer Bill of Rights & Responsibilities, HIPAA Privacy Notice, DME Supplier Standards and Community Resources (view Sections 2 through 10).
  • I acknowledge that I have been trained and/or will be trained on the use, cleaning and maintenance of all products I receive from Acelleron.
  • I agree that Acelleron may contact me in the future, via telephone, email, or regular mail.
  • Owner’s manual with warranty information has been or will be provided to me for all durable medical equipment.
  • The equipment remains the property of Medela, Inc. McHenry, IL. Lessee has no rights to such equipment except as expressed in this Agreement.
  • Lessee agrees to inform Acelleron of any change of address.
  • Lessee agrees not to move the equipment out of this State without the consent of Acelleron.
  • Lessee agrees to allow no person other than Lessee to use the equipment provided.
  • Lessee agrees to return the equipment in clean condition and if not agrees to pay a $25 cleaning fee to Acelleron.
  • Lessee agrees to return the equipment in good repair.
  • This agreement shall be construed under the laws of Massachusetts.
  • The Lessee shall be responsible for all reasonable legal fees and other costs involved in collection of overdue amounts and/or recovery of equipment.
  • Acelleron has the right to cancel this agreement at any time with three days’ notice.
  • Lessee agrees to allow Acelleron, Medela, Inc. or any agency involved in collection of overdue amounts and/or equipment to obtain a credit report on Lessee.
  • Failure to return the breast pump to Acelleron Medical Products will result in the Lessee owing Acelleron $2,500.00.
  • I certify that I have read the terms and conditions of this agreement, any attachments and agree to its content.

ACELLERON WARRANTS TO REPAIR OR REPLACE ANY EQUIPMENT WHICH IS OR BECOMES DEFECTIVE UNDER NORMAL USE. ACELLERON AND MEDELA, INC. WILL NOT BE LIABLE FOR INCIDENTAL, CONSEQUENTIAL OR ANY OTHER DAMAGES RESULTING FROM DEFECTIVE EQUIPMENT; THEIR LIABILITY IS LIMITED TO REPAIR OR REPLACEMENT OF THE EQUIPMENT. THIS WARRANTY IS GIVEN IN LIEU OF ALL OTHER WARRANTIES EXPRESSED OR IMPLIED.

SECTION TWO: Hours of Availability
Acelleron Medical Products (“Acelleron”) is available to serve our customers Monday through Thursday from 9:00 am to 6:00 pm, Friday 9:00 am to 5:00 pm, Saturday 9:00 am to 3:00 pm. Acelleron maintains emergency, on call service for any calls outside normal business hours. To contact us during and after business hours, please call 877-932-6327.

SECTION THREE: Instructions for Set-Up of Durable Medical Equipment
Trained staff are available during and after business hours at 877-932-6327 to answer client questions and to provide our clients with any assistance they may need. Please also refer to the manufacturer’s product manuals and guidelines, or visit our Knowledge Center at acelleron.com/knowledge.

SECTION FOUR: Safety Precautions
Please make sure you read all instructions before using equipment. In addition, please visit acelleron.com/safety to view the Safety Precautions for electrical equipment, batteries, respiratory devices and fire safety.

SECTION FIVE: Emergency or Natural Disaster
If you are in need of emergency medical treatment during a natural disaster or other medical emergency, contact 911.

SECTION SIX: Client Suggestions or Complaints
We value your suggestions and we will work hard to resolve any complaints. If you have a suggestion or a complaint, please call Acelleron at 877-932-6327 and your call will be handled in a professional and confidential manner. You will be asked to provide your name, address, telephone number, health insurance number, if applicable, and a summary of the complaint. All logged complaints are received by management within 1 business day and the client will be contacted by management within 2 business days. To help maintain the highest level of professional service possible, we invite you to visit our website and fill out our satisfaction survey at acelleron.com/survey. You also have the right to register a complaint with the company’s accrediting body, Community Health Accreditation Program (“CHAP”) by calling 800-656-9656 Monday through Friday from 8:00 am to 6:00 pm.

SECTION SEVEN: Client Bill of Rights and Responsibilities
Acelleron recognizes you have rights as a client receiving medical products or services. In return, there are responsibilities for certain behavior on the part of the client. We believe that all clients receiving products or services from Acelleron should be informed of their rights and responsibilities. The full text of Client Rights and Responsibilities can be found at acelleron.com/responsibilities. Upon request we will furnish you a written copy of this document.

SECTION EIGHT: HIPAA Notice of Information/Privacy Practices
Acelleron is dedicated to maintaining the privacy of your identifiable health information. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time. The purpose of this notice is to inform you, the client, how your personal health information is used and/or disclosed by Acelleron as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of Acelleron. The full text of the HIPAA/Privacy Notice can be found at acelleron.com/privacy. Upon request we will furnish you a written copy of this document.

SECTION NINE: DME Supplier Standards
The products and/or services provided to you by Acelleron Medical Products are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be found at acelleron.com/supplierstandards. Upon request we will furnish you a written copy of this document.

SECTION TEN: Community Resources

Breastfeeding – Visit lactationlink.com or zipmilk.org

American Red Cross – Visit redcross.org or call (800) 733-2767