I agree to the following: *
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.

[1] I hereby authorize Neb Doctors/Pumps for Mom (herein referred to as ‘Provider’) to provide the equipment prescribed above. I understand that Provider is an independent company and not part of any other medical practice, hospital or other company. [2] I understand if my insurance coverage is denied or if I have a deductible or co-pay to meet, I am responsible for paying the Provider the usual and customary price for the above-listed product(s). [3] For a copy of the Provider’s Privacy Policy, Patient/Client Rights and Responsibilities, Supplier Standards, and Provider Policies, visit www.pumpsformom.com/resources. User Manuals can be found on the product’s page. [4] I certify that I have read the terms and conditions of this agreement with the attachments listed above and agree to its content. I have also been instructed on properly and safely using the above-listed equipment. [5] I authorize the Provider to contact me by phone, email, or text. We will not share this information.