I acknowledge I have not received a personal use breast pump through this insurance policy or any other insurance policy for this pregnancy. I understand if I have received a breast pump through another provider or insurance coverage this claim may be denied and I will be responsible for paying the full retail value of the breast pump to Acelleron Medical Products.
I would like to receive email updates from Acelleron Medical Products.
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 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 the 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 confirm that I DO NOT have Blue Cross Complete of Michigan Medicaid plan (Prefix on card: XYU).
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 am NOT listed as a dependent on my parent's health insurance policy.
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 acknowledge that I have not received a breast pump through my Husky Medicaid insurance in the last two years.
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 acknowledge that I have not received a breast pump through my Husky Medicaid insurance in the last two years.
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.
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.
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