Purchase Consent

Patient Name*

First Last

Date of Birth*

I authorize Neb Medical Services, Inc., to directly bill Medicare, Medicaid, Medicare Supplemental, or other insurer(s) on my behalf, for medical supplies furnished to me by Neb Medical Services and assign my rights and benefits from such insurers to Neb Medical Services. I authorize any holder of medical information about me to release to Neb Medical Services, my physician(s), caregiver, CMS, and its agents. I authorize Neb Medical Services to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies provided.
All medical supplies come with a manufacturer’s warranty. The warranty is included in the box with your product and varies based on the brand. Please contact the manufacturer directly if you have any problems with your product or need additional information regarding the warranty. Keep your Neb Medical Proof of Purchase included with your shipment, as it may be required for manufacturer replacement.
Any returns or exchanges must be made within 45 days of purchase, in the original condition, and with packaging intact. Neb Medical will only pay return shipping for damaged or incorrect items.
Orders can be cancelled at any time prior to shipment.
If the product selected displays an “upgrade charge”, I agree to pay this upgrade charge out-of-pocket and understand the charge is above and beyond the charge to my insurance company for the product selected. By selecting a product with an upgrade charge, I understand this charge is non-covered by my insurance and I waive my right to seek compensation from my insurance company for the upgrade charge.

Insurance Frequency Information

Have you received a breast Pump through your current insurance plan in the past 5 years?*

If yes, then have you received a breast pump from another provider during this pregnancy?*

If yes, then please provide the approximate year.*