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 I have an Amerihealth commercial plan, and not AmeriHealth Caritas of DE Medicaid plan. Otherwise, I will be responsible for payment.
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 authorize Acelleron to share my information with their sister company, Ortho-Tek, Inc., an in-network provider with BCBS of TX, who will handle the billing for my breastfeeding equipment and supplies.
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 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 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.
