Authorization and Consent

Terms & Conditions

Authorization and Consent

Statement to Permit Payment of Insurance Benefits to Provider, Physician and Patient: I request that payment of authorized Medicaid, Medicare and/or private insurance benefits be made to me or, on my behalf, to Yummy Mummy, LLC for any services or products furnished to me b Yummy Mummy. I authorize a copy of this agreement to be used in place of the original.

I further authorize any holder of medical information about me to release any information needed to determine eligibility or reimbursement to Yummy Mummy, LLC, my physician (s), caregiver, Centers for Medicare and Medicaid Services and its agents, my insurance company or others.

Optional Upgrade: I agree to pay all amounts that are not covered by my insurer(s) including an upgrade that I authorize and for which I am financially responsible. I understand that the credit card information I provided at the time of my order for an upgrade is an authorization hold to confirm that the account is active and funded. The funds will not be captured until the order is completed and shipped. I realize that there may be a time lag between when I am charged for my upgrade pump and when my upgrade pump ships. I am aware that upgrade pumps are subject to the same insurer guidelines as other pumps. I understand that I will be refunded for the upgrade fee if I decide to cancel my order before it has shipped.

Plan of Care: I acknowledge that I have participated in the development of the plan of care or service for me and any changes in that plan prior to the beginning of services and as subsequent changes occur. I acknowledge that the plan of care/service was reviewed and accepted by me. I also acknowledge that Yummy Mummy does not supply ongoing services or products that are not specifically requested by a customer or the physician that has responsibility for the customer care or service. I hereby acknowledge that I am aware that Yummy Mummy does not supply currently prescribed products or services unless requested by me or my physician.

Product Training, Cleaning and Maintenance: I acknowledge that I have been either given the opportunity to be trained on the use, cleaning and maintenance of all the insurance products I receive from Yummy Mummy and/or will receive instructional information pertaining to the use, cleaning and maintenance of all the insurance products I receive from Yummy Mummy and/or have access to instructional information pertaining to the use, cleaning and maintenance of all the insurance products I receive from Yummy Mummy on the Yummy Mummy website.

Follow-up: I agree that Yummy Mummy may contact me in the future, via telephone, email, text message or regular mail, regarding this purchase.

Warranty Information: I understand that all personal-grade breast pump products sold by Yummy Mummy carry at least a 1-year manufacturer’s warranty. In addition, when available, an owner’s manual with warranty information has been or will be provided to me for all durable medical equipment. I am also aware that Yummy Mummy will send any broken rental pumps back to the manufacturer, free of charge.

HIPAA Privacy Information: I agree that I have read the Yummy Mummy HIPAA privacy practices located on the Yummy Mummy website, explaining how my personal health information is and can be disclosed by Yummy Mummy.

DME Scope or Services / Customer Rights and Responsibilities: I agree that I have read the Yummy Mummy DME Scope of Services / Customer Rights and Responsibilities document located on the Yummy Mummy website. This document includes but is not limited to information regarding emergency preparedness.

All Sales Final: I understand and agree that all sales of products covered under insurance are final, and that there are no returns or refunds.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with the Privacy Rule of Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

1. This authorization does not include disclosure of information relating to ALCOHOL AND DRUG ABUSE, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV RELATED INFORMATION.

2. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

3. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

4. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU, MY PHYSICIAN, TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN MY INSURER AND YUMMY MUMMY.

5. Name and telephone number of health provider/OB/GYN to release this information will be as you have supplied in the form above.

6. This information will be faxed to: YUMMY MUMMY at 855-291-5930 (secure fax)

7(a). Specific information to be released: CONFIRMATION OF PATIENT'S PREGNANCY AND/OR DUE DATE AND/OR DELIVERY DATE, including PRESCRIPTION/ORDER FOR A BREAST PUMP

7(b). Authorization to Discuss Health Information: By signing this form, I authorize my OB/GYN to discuss my health information with Yummy Mummy.

8. Reason for release of information: REQUEST OF INDIVIDUAL

9. Date or event on which this authorization will expire: One year after the patient's due date.

All items on this form have been completed and my questions about this form have been answered. In addition, I can request a copy of this signed form at any time.

Yummy Mummy

1751 Second Avenue Suite 203, NYC

(212) 879-8669 / (855) 879-8669

HIPAA: Notification of Information Practices and Consent

Notification of Information Practices Summary and Consent As Required by HIPAA

The purpose of this notice is to inform you, the customer, how your personal health information is used and/or disclosed by Yummy Mummy, LLC as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We want you to be fully aware of what we do with your information so that you can provide us with your consent in order for us to treat your health care needs, receive payment for services rendered, and allow administrative and other types of health care operations to happen, which are part of normal business activities of Yummy Mummy.

Definitions

1. HIPAA — Health Insurance Portability and Accountability Act is a federal law that protects the privacy of people's health information held by health insurers and providers.

2. PHI — Protected Health Information includes a customer’s name, address, birth date, Social Security Number and any information that is related to the individual's past, present or future physical condition, the provision of health care to the individual, or the past, present or future payment for the provision of health care to the individual and that identifies the individual, or for which there is a reasonable basis to believe it can be used to identify the individual.

3. EPHI — Electronic Protected Health Information: The Privacy Rule under HIPAA protects all PHI in any form or media, whether electronic, paper or oral. The types of information covered by this policy include electronic and computerized information, telephone and cell phone communications, and verbal or faxed communication.

Your consent

I understand that as part of my health care, this organization originates and maintains health records, where applicable, describing my health history, symptoms, test results, diagnoses, treatment, and plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment.

A means of communication among my diagnosis/es and other health information to my bill(s).

A source of information for applying my diagnosis/es and other health information to my bill(s).

A means by which my health plan or health insurance company can verify that services billed were actually provided.

A tool for routine health care operations in this organization, such as ensuring that we have quality processes and programs in place and making sure that the professionals who provide your care are competent to do so.

I understand that:

I have been provided with a Notice of Information / Privacy Practices that provides specific examples and descriptions of how my personal health information is used and disclosed by Yummy Mummy;

I have the right to review the Notice of Information / Privacy Practices;

Yummy Mummy can change its Notice of Information / Privacy Practices but notify me of those changes before they are put into practice and will mail me a copy of the new Notice to the address that I have provided;

I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations and that Yummy Mummy is not required to agree to those restrictions;

Any restrictions to which Yummy Mummy agrees to will be respected.

I may revoke this consent in writing at any time. Further, I am aware that Yummy Mummy can proceed with uses and disclosures that pertain to treatment, payment, or healthcare issues that took place before the consent was revoked.

Learn More About HIPAA

As Required by the Privacy Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Actof1996 (HIPAA)

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO YOUR IDENTIFIABLE HEALTH INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

A. OUR COMMITMENT TO YOUR PRIVACY

Our organization is dedicated to maintaining the privacy of your identifiable health information.

In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy practices concerning your identifiable health information. By law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

To summarize, this notice provides you with the following important information:

IZ How we may use and disclose your identifiable health information

IZ Your privacy rights in your identifiable health information

IZ Our obligations concerning the use and disclosure of your identifiable health information.

The terms of this notice apply to all records containing your identifiable health information that are created or retained by our practice. We reserve the right to revise or amend our notice of privacy practices. Any revision or amendment to this notice will be effective for all of your records our practice has created or maintained in the past, and for any of your records we may create or maintain in the future. Our organization will post a copy of our current notice in our offices in a prominent location, and you may request a copy of our most current notice during any office visit.

B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Compliance Officer, Yummy Mummy, LLC,

1751 Second Avenue Suite 203

New York, NY

10028

(212) 879-8669; (855) 879-8669

C. WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION IN THE FOLLOWING WAYS

The following categories describe the different ways in which we may use and disclose your identifiable health information:

1. Treatment. Our organization may use your identifiable health information to treat you. For example, we may perform a follow-up interview and we may use the results to help us modify your treatment plan. Many of the people who work for our organization may use of disclose your identifiable health information in order to treat you or to assist others in your treatment. Additionally, we may disclose your identifiable health information to others who may assist in your care, such as your physician, therapists, spouse, children, or parents.

2. Payment. Our organization may use and disclose your identifiable health information in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your identifiable health information to obtain payment from third parties who may be responsible for such costs, such as family members. Also, we may use your identifiable health information to bill you directly for services and items.

3. Health Care Operations. Our organization may use and disclose your identifiable health information to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our organization may use your health information to evaluate the quality of care you received from us or to conduct costmanagement and business planning activities for our practice.

4. Appointment Reminders. Our organization may use and disclose your identifiable health information to contact you and remind you of visits/deliveries.

5. Health-Related Benefits and Services. Our organization may use and disclose your identifiable health information to inform you of health-related benefits or services that may be of interest to you.

6. Release of Information to Family/Friends. Our organization may release your identifiable health information to a friend or family member who is helping you pay for your health care of who assists in taking care of you.

7. Disclosures Required By Law. Our organization will use and disclose your identifiable health information when we are required to do so by federal, state, or local law.

D. USE AND DISCLOSURE OF YOUR IDENTIFIABLE HEALTH IN CERTAIN SPECIAL CIRCUMSTANCES The following categories describe unique scenarios in which we may use or disclose your identifiable health information:

1. Public Health Risks. Our organization may disclose your identifiable health information to public health authorities who are authorized by law to collect information for the purpose of :

o Maintaining vital records, such as births and deaths

o Reporting child abuse or neglect

o Preventing or controlling disease, injury, or disability

o Notifying a person regarding potential exposure to a communicable disease

o Notifying a person regarding a potential risk for spreading or contracting a disease or condition

o Reporting reactions to drugs or problems with products or devices

o Notifying individuals if a product or device they may be using has been recalled

o Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information

o Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health Oversight Activities. Our organization may disclose your identifiable health information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.

3. Lawsuits and Similar Proceedings. Our organization may use and disclose your identifiable health information in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We also may disclose your identifiable health information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release identifiable health information if asked to do so by a law enforcement official:

o Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

o Concerning a death we believe might have resulted from criminal conduct

o Regarding criminal conduct at our offices

o In response to a warrant, summons, court order, subpoena, or similar legal process

o To identify/locate a suspect, material witness, fugitive, or missing person

o In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

5. Serious Threats to Health or Safety. Our organization may use and disclose your identifiable health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

6. Military. Our organization may disclose your identifiable health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities.

7. National Security. Our organization may disclose your identifiable health information to federal officials for intelligence and national security activities authorized by law. We also may disclose your identifiable health information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

8. Inmates. Our organization may disclose your identifiable health information to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary:

(a) for the institution to provide health care services to you; (b) for the safety and security of the institution; and/or (c) to protect your health and safety or the health and safety of other individuals.

9. Workers’ Compensation. Our organization may release your identifiable health information for workers’ compensation and similar programs.

E. YOUR RIGHTS REGARDING YOUR IDENTIFIABLE HEALTH INFORMATION

You have the following rights regarding the identifiable health information that we maintain about you:

1. Confidential Communications. You have the right to request that our organization communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028 specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your identifiable health information for the treatment, payment, or health care operations. Additionally, you have the right to request that we limit our disclosure of your identifiable health information to individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your identifiable health information, you must make your request in writing to Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028. Your request must describe in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice’s use, disclosure, or both; and (c) to whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the identifiable health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028 in order to inspect and/or obtain a copy of your identifiable health information. Our organization may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Reviews will be conducted by another licensed health care professional chosen by us.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our organization. To request an amendment, your request must be made in writing and submitted to Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028. You must provide us with a reason that supports your request for amendment. Our organization will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is: (a) accurate and complete;

(b) not part of the identifiable health information kept by or for the organization; (c) not part of the identifiable health information which you would be permitted to inspect and copy; or (d) not created by our organization, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. All of our patients have the right to requests an “accounting of disclosures.” An “accounting of disclosures” is a list of certain disclosures our organization has made of your identifiable health information. In order to obtain an accounting of disclosures, you must submit your request in writing to Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028. All requests for an “accounting of disclosures” must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you additional lists within the same 12-month period. Our organization will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our organization, Compliance Officer, Yummy Mummy, LLC, 1751 Second Avenue Suite 203, New York, NY 10028. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note that we are required to retain records of your care.

DME Scope of Services Policy

Yummy Mummy, LLC ("Yummy Mummy") offers durable medical equipment for breastfeeding for sale. Our goal is to provide quality breast pumps and accessories to our customers. Products and Services Available

(1) Breast Pumps;2) Breast Pump Supplies and Accessories;(3) Products for Breast Care and Postpartum Care;(4) Bottle Products and Accessories;(5) Nursing Bras and Clothing; and (6) Classes and Support Groups.

Hours of Availability

Yummy Mummy provides the following hours of service to its customers: Monday, Tuesday, Thursday and Friday: 10:00 a.m. to 6:00 p.m.; Wednesday: 10:00 a.m. to 8:00 p.m., and Saturday: 11:30 a.m. to 5:00 p.m. The store is closed on Sundays.

Delivery Services

Yummy Mummy will use the least expensive and most appropriate method of delivery to ship covered equipment to customers request within a 12-month period is free of charge, but our practice may charge you for Emergency Preparedness

In an emergency outside of normal business hours, customers can call Yummy Mummy at (212) 879-8669, which provides information for an email address (info@yummymummystore.com) that is checked 24/7 as well as an after-hours service. This number, (212) 879-8669, is operated by Vonage, a publicly-held commercial voice-over-IP (VOIP) network and SIP company that provides telephone service via a broadband connection.

Customers should call the after-hours service or can choose to leave a brief message explaining the difficulty with the equipment or regarding a missed delivery, and the Company will immediately forward calls to appropriate and available personnel during regular business hours. In addition, the voicemail message at the number will be updated with specific information about any interruption of service events.

Yummy Mummy also uses its website, Facebook page and Twitter handle to inform customers of any planned or unexpected interruption of service events. Yummy Mummy has a large email list which we can and do use to distribute messages to customers related to any interruption of service.

Instructions for Set-Up of Breast Pumps

Properly trained staff is available during store hours to answer customers’ questions and to provide our customers with any assistance they may need. Please also refer to manufacturer’s product manuals or guidelines.

Instructional videos on how to assemble, use and care for your pump to ensure the best results for you and your baby are available here on our website. Yummy Mummy instructs all customers to use a properly grounded outlet and we strongly discourage the use of extension cords to plug in your breast pump unless absolutely necessary./p>

Customer Suggestions or Complaints

We value your suggestions and we will work hard to resolve any complaints. If you have a suggestion or a complaint, please call Yummy Mummy during our business hours and your call will be handled in a professional and confidential manner. You will be asked to provide your name, address, telephone number, and health insurance number, if applicable, and a summary of the complaint. Yummy Mummy's Compliance Officer will be informed of your complaint. All logged complaints will be investigated, acted upon, and responded to within five (5) working days after receipt of the complaint. If there is no satisfactory resolution of the complaint, the next level of management will be notified progressively up to the President/Owner of Yummy Mummy. All complaints are reviewed quarterly by the Quality Improvement Team and are kept confidential. In the event that your complaint remains unresolved with Yummy Mummy, you may file a complaint with our Accreditor, The Compliance Team, via their website at www.thecomplianceteam.org or by phone at (888) 291-5353. You may also contact the New York State Division of Consumer Protection.

Florida Medicaid Fraud: Medicaid fraud is defined by the Florida Agency for Health Care

Administration (AHCA) as "an intentional deception or misrepresentation made by a health care provider with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under federal or state General toll-free at (866) 966-7226. Callers can request to remain anonymous.

Customer’s Rights & Responsibilities

Customer Rights

1. The customer has the right to be fully informed in advance about services to be provided as well as any modifications to the plan of care.

2. The customer has the right to be informed, orally or in writing, in advance of services being provided of the charges, including payment for service expected from third parties and any charges for which the customer will be responsible.

3. The customer has the right to receive information about the scope of services that the Company will provide and specific limitations on those services.

4. The customer has the right to participate in the development and periodic revision of the plan of care.

5. The customer has the right to refuse care or treatment after the consequences of refusing care or treatment are fully presented.

6. The customer has the right to have his or her property and person treated with respect, consideration, and recognition of customer dignity and individuality.

7. The customer has the right to be able to identify visiting personnel members through proper identification: purple Yummy Mummy shirts.

8. The customer has the right to be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of client property. If you are a Florida resident, please note that to report abuse, neglect, or exploitation, you may call toll-free (800) 962-2873.

9. The customer has the right to voice grievances/complaints regarding treatment or care, lack of respect of property, or to recommend changes in policy, personnel, or services without restraint, and without fear of interference, coercion, discrimination, or reprisal in the service process. If you are a Florida resident, please note that to report a complaint regarding the services you receive, please call toll-free (888) 419-3456.

10. The customer has the right to be fully informed about Medicaid fraud.

11. The customer has the right to have and voice grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property, investigated.

12. The customer has the right to confidentiality and privacy of all information contained in the customer’s record and of Protected Health Information.

13. The customer has the right to be advised on Company’s policies and procedures regarding the disclosure of clinical records.

14. The customer has the right to choose a health care provider, including choosing an attending physician or Durable Medical Equipment provider, if applicable.

15. The customer has the right to receive appropriate care without discrimination in accordance with physician’s orders, if applicable.

16. The customer has the right to be informed of any financial benefits when referred to an organization.

17. The customer has the right to be fully informed of one’s responsibilities.

law related to Medicaid." To report suspected Medicaid Fraud, please call the Florida Attorney CustomerResponsibilities

1. The customer should promptly notify Yummy Mummy of any equipment failure or damage.

2. The customer is responsible for any rental equipment that is lost or stolen while in their possession and should promptly notify Yummy Mummy in such instances.

3. The customer should promptly notify Yummy Mummy of any changes to their address or telephone or credit card information.

4. The customer should promptly notify Yummy Mummy of any changes concerning their physician.

5. The customer should notify Yummy Mummy of discontinuance of use.

6. Except where contrary to federal or state law, the customer is responsible for any equipment rental and sale charges which the customer’s insurancecompany/companies does not pay