On Site Breast Pump Order

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*
Breast Pump Model Provided to you*
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*
Mother's Email*
Mother's Phone*
Mother's Date of Birth*
MM slash DD slash YYYY
Today's Date*
MM slash DD slash YYYY
Mother's Signature*
Name
This field is for validation purposes and should be left unchanged.

Please complete the on site order form below and acknowledge terms.

Select the statement that applies to you:

What is the name of hospital staff member that helped you with this order?

Please Sign and Date