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 understand that I have selected a wearable breast pump. Wearable pumps are generally intended for occasional use as a secondary pump. Primary/traditional pumps typically provide stronger suction, more powerful motors, and greater customization which may help maintain milk supply and pump more efficiently. By checking this box, I acknowledge that I understand this difference.
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 confirm that I DO NOT have Blue Cross Complete of Michigan Medicaid plan (Prefix on card: XYU)
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 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.
