Elvie Double Electric Breast Pump

I have been offered the standard double electric breast pump that is fully covered by my insurance: however, I am opting to upgrade to a deluxe model. I am aware that the breast pump I am ordering is a deluxe model and will be responsible for the difference between the reimbursement rate of the standard model and the deluxe model.

You will be charged $95 along with any upgrade fees associated to your pump of choice. The $95 accounts for the expected reimbursement which will be paid directly to you as the member and not us as the provider. We will submit your insurance claim but payment for the claim will be directed to you as the plan member and not our organization.

Charges seen on your credit card statement will reflect LACTATION SERVICES LLC. Your credit card will be authorized for the full amount of purchase price for the pump and accessories but will only be charged the discounted price of pump and accessories. If your insurance denies the claim we will charge the balance at that time (discount given) and provide you with the reason for such denial. Sometimes insurance companies deny claims because you may have already received a breast pump during this pregnancy, you may have terminated your insurance plan or your specific plan requires a deductible.

If in our opinion an appeal of the insurance companies decision is warranted we will still charge your credit card for the discount given, file the appeal and if successfully appealed and payment subsequently received we will credit your credit card account and will notify you of such

The product I am requesting is considered an FDA device and once the seal on the manufacturer box has been broken I am not able to request a return or exchange. If the seal on the manufacturer box has not been broken I will be able to request an exchange or return by contacting breastpumps.com. A sticker will be included on the exterior packaging of the breast pump indicating the box should not be open until the baby is born. This reminder is designed to allow me an opportunity to discuss and coordinate with my clinical team on the correct product selection and to avoid opening the package and then request an exchange which cannot be provided. In the event I have already broken the manufacturer seal on the package I will not be eligible for an exchange but can request a private purchase discount be made available for a different pump selection of my choice.

I acknowledge that I am responsible for paying any difference between the allowed amount from my Insurers and the DME Providers charges for an upgraded breast pump, code E0603. My Plan allows for reimbursement to the Provider, for the least costly item that meets my needs. I am fully aware I am taking on all obligation beyond my insurance payment for my electric breast pump code E0603. I have chosen to select a pump that is not fully covered by my Insurance as it is an upgrade. I have been given the option of choosing a breast pump that does not require an out of pocket payment other than potential co insurance. In choosing an upgrade, I give up any right to dispute the remaining balance due, either with the provider (HBE) or to the primary insurer of record.

I request that payment of authorized insurance and other benefits be made on my behalf to Breastpumps.com (BP.com) or its affiliates for the products and services that they have provided for me. I authorize BP.com to bill my insurance company for the equipment listed above and I agree to pay any copays or other charges not covered by my insurance. BP.com will notify me prior to shipping of any listed copays. If, for any reason, my insurer denies the claims through no fault of BP.com, I will be billed, and will pay BP.com, for this pump. I further authorize a copy of this agreement to be used in place of the original and authorize any holder of medical information about me to release to BP.com any information needed to determine these benefits or compliance with current healthcare standards including HIPAA. By signing below I acknowledge I have read and understand this notice. BP.com is not the specific manufacturer of the breast pump options herein and therefore is not liable for the unanticipated malfunction of any pump. If, in the unlikely instance a breast pump does not function for its intended use for any reason, you can contact the manufacturer of your chosen pump and request a replacement pursuant to the specific warranty of that pump, as applicable.