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On Site Breast Pump Order
Get Started
Please complete the on site order form below and acknowledge terms.
Select the statement that applies to you:
How pump is being received
*
I received a personal use breast pump at the hospital
I am ordering a personal use breast pump to be shipped to me
Inventory/Facility Location
*
Inventory/Facility Location
Hospital of the University of Pennsylvania
Breast Pump Model Provided to you
*
Breast Pump Model Provided to you
Ameda Finesse Dottie Tote (101A07)
Medela Personal Double (101035077)
Medela PIS Backpack (57062) - Upgrade
Medela PIS Metro Bag (57036) - Upgrade
Spectra S2
Spectra S1 - Upgrade
Please call Acelleron at 978-738-9800 x1 to process your credit card payment for your breast pump upgrade.
Breast Pump Lot #
*
Name of hospital staff member that helped you with this order
What is the name of hospital staff member that helped you with this order?
Please Read and Acknowledge Terms:
I understand that Acelleron Medical Products (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
I certify that the information provided by me and applying for payment under Title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits.
Upgrade Waiver (only applies if mom decides to upgrade): I have been offered the standard double electric breast pump that is fully covered by my insurance; however, I am opting to upgrade to a deluxe model. I am aware that the breast pump I am purchasing is a deluxe model, and that I will be responsible for the difference between the price of the upgraded model and the reimbursement rate for the standard model charges. Not available to Medicaid beneficiaries.
I understand that if my insurance coverage is denied, I am responsible to pay Provider the usual and customary amount/ price for this equipment.
Every electric breast pump carries at least a one-year manufacturer’s warranty. Specific warranty length and information is described in the manufacturer’s owners’ manual.
I authorize release of all medical records needed in relation to the above-referenced equipment.
I certify that I have received this breast pump in good and working order.
I acknowledge that I have been trained and/or will be trained on the use, cleaning and maintenance of all products I receive from Provider.
I agree that Provider may contact me in the future, via text, telephone, email or regular mail.
I certify that I have been provided the Hours of Availability, Community Resources, Instructions for Set-Up of HME, Safety Precautions, Emergency or Natural Disaster Information, Customer Complaint Policy, Customer Bill of Rights & Responsibilities, HIPAA Privacy Notice and DME Supplier Standards at
acelleron.com/breast-pumps/terms/
Please Read and Acknowledge Terms:
I understand that Acelleron Medical Products (“Provider”) is independently owned and operated and is not in any way associated with a hospital, medical practice or any other clinic.
I certify that the information provided by me and applying for payment under Title XVIII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
I request that a payment be made to Provider by my insurance company, Medicaid, Medicare or government benefits.
I understand that if my insurance coverage is denied, I am responsible to pay Provider the usual and customary amount/ price for this equipment.
Upgrade Waiver (only applies if mom decides to upgrade): I have been offered the standard double electric breast pump that is fully covered by my insurance; however, I am opting to upgrade to a deluxe model. I am aware that the breast pump I am purchasing is a deluxe model, and that I will be responsible for the difference between the price of the upgraded model and the reimbursement rate for the standard model charges. Not available to Medicaid beneficiaries.
Every electric breast pump carries at least a one-year manufacturer’s warranty. Specific warranty length and information is described in the manufacturer’s owners’ manual.
I authorize release of all medical records needed in relation to the above-referenced equipment.
I acknowledge that I have been trained and/or will be trained on the use, cleaning and maintenance of all products I receive from Provider.
I agree that Provider may contact me in the future, via text, telephone, email or regular mail.
I certify that I have been provided the Hours of Availability, Community Resources, Instructions for Set-Up of HME, Safety Precautions, Emergency or Natural Disaster Information, Customer Complaint Policy, Customer Bill of Rights & Responsibilities, HIPAA Privacy Notice and DME Supplier Standards at
acelleron.com/breast-pumps/terms/
Please read and check the box
*
I have read and agree to the terms and conditions listed above.
Please Sign and Date
Mother's First Name
*
Mother's Last Name
*
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*
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*
Mother's Date of Birth
*
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Mother's Signature
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