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 by 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 of Medicare and Medicaid Services and its agents, my insurance company or others. I agree to pay all amounts that are not covered by my insurer(s) and for which I am responsible.

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, or regular mail, regarding this purchase.

Warranty Information. I understand that all personal-grade breast pump products sold by Yummy Mummy carry 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. Furthermore, I understand that Yummy Mummy will replace or swap, free of charge, hospital-grade breast pumps that fail to operate or are defective while in my possession with a working hospital-grade pump. 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.