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Expecting Mother's Information
Physicians Information
Insurance Information
  • I acknowledge I have not received a personal use breast pump & supplies (and/or replacement supplies) through this insurance policy or any other insurance policy for this pregnancy. I understand if I have received a breast pump & supplies (and/or replacement supplies) 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 & supplies (and/or replacement supplies) to The Breastfeeding Shop. Additionally, I understand I am ultimately responsible for any unpaid charges for the breast pump & supplies (and/or replacement) if my insurer denies the claim for any reason.

  • I acknowledge that I have access to The Breastfeeding Shop's Privacy, Rights & Responsibility as well as the Supplier Standards, which are available to me in the link below.

  • Use your mouse or finger to draw your signature above. Assignment of benefits and release of information: By signing this, I authorize my insurance company who is responsible for paying for my care to pay benefits on my behalf directly to The Breastfeeding Shop for any products or services that were rendered to me by The Breastfeeding Shop. I also authorize The Breastfeeding Shop to request, on my behalf, all public and private insurance benefits for products provided to me by The Breastfeeding Shop. I hearby authorize The Breastfeeding Shop to release my medical records to any person, organization, company and/or agency which is or may be 1. Involved in providing care for me or 2. liable for any portion of the payment of the charges for such products and services. I also acknowledge by signing this form that if my insurance company reimburses for replacement supplies that my signature means that I agree to receive those items with my initial breast pump order, such as replacement tubing, caps, locking rings, bottles, flanges & milk storage bags.