Terms and Conditions Acknowledgement
I acknowledge that if I have coverage under more than one insurance policy that I have listed both insurances in the proper Primary and Secondary insurance sections. If I do not, I may be responsible for payment in full if my claim is denied by the Primary listed insurer.
I have been offered a "basic" or "standard" breast pump through my insurance, but decided to purchase a "deluxe" model. I will be responsible for paying Acelleron the difference between the price of the deluxe model and the reimbursement rate of the standard or basic model.
I acknowledge and authorize my credit card to be run for any out-of-pocket responsibilities including deductibles, co-insurance, upgrades, and/or retail expenses. I also understand the timing of credit card charges is based on my insurance guidelines, which means my card will be charged when Acelleron is able to ship my equipment and/or when/if my claim is finalized.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I acknowledge that if my member ID prefix starts with anything but "KSE" that I have not previously received a breast pump through my BCBS of KS insurance. Otherwise, I will be responsible for paying for the breast pump. KSE members are allowed 1 pump per pregnancy. All other BCBS of KS prefixes only allow 1 pump per lifetime.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a MyBlue Health plan with a T2G prefix. These plans are out of network, please call your health insurance member services for an in-network provider.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I acknowledge that If my insurance plan does not follow the Affordable Care Act (ACA) guidelines for breast pump coverage, Acelleron will contact me to obtain my credit card information. This information will be kept on file and may be used if the cost of the breast pump is applied to my deductible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that my Health Plans insurance is administered by Harvard Pilgrim. I understand that if my Health Plans insurance is NOT administered by Harvard Pilgrim, I may be responsible for the cost of pump and any accessories if my claim denies.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that I have not received a breast pump through my Husky Health insurance plan within the last two years and acknowledge that my health insurance only pays for one breast pump once every two years.
I do not have a Federal BCBS plan (Member ID begins with “R”). Federal BCBS members must order through FEPBlue.org.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that I have not received a breast pump through my Husky Health insurance plan within the last two years and acknowledge that my health insurance only pays for one breast pump once every two years.
I confirm that I do not have a Emergency Medicaid plan as breast pumps are not covered | Confirmo que no tengo un plan de emergencia de Medicaid porque los extractores de leche no están cubiertos con este plan específico.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
I confirm that the Medicaid plan I selected is my primary insurance and I have no other coverage with any other insurance. Otherwise, I may be responsible if Medicaid denies the claim due to another insurance being responsible.
