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 agree to receive marketing text messages from Acelleron. Message frequency varies. Message & data rates may apply. Reply STOP to opt out, HELP for help.
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 acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I confirm that the Medicaid Plan I selected is my primary insurance and I have no other coverage with any other insurance.
I confirm that the Medicaid Plan I selected is my primary insurance and I have no other coverage with any other insurance.
I confirm that the Medicaid Plan I selected is my primary insurance and I have no other coverage with any other insurance.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I confirm that the Medicaid Plan I selected is my primary insurance and I have no other coverage with any other insurance.
I acknowledge that I have not received a breast pump through my HUSKY Medicaid insurance in the last two (2) years.
I confirm that the Medicaid Plan I selected is my primary insurance and I have no other coverage with any other insurance.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my HUSKY Medicaid insurance in the last two (2) years
I confirm that the Medicaid Plan I selected is my primary insurance and I have no other coverage with any other insurance.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.
I acknowledge that I have not received a breast pump through my NY Medicaid insurance in the last three (3) years.