I hereby authorize Pumps for Mom by Neb Doctors (herein referred to as “Provider”) to provide the equipment prescribed above and understand that Provider is an independent company and not part of any medical practice, hospital, or any other company.
I certify that the information provided by me above in applying for payment under title XVII (Medicare) of the Social Security Act or any other insurance benefits is true and correct.
I understand that I am personally responsible to Provider for balance not paid in full by insurance coverage, whether applied to deductible or co-pay responsibilities or, in the absence of insurance coverage, the total balance. The portions of any bill for which I am responsible are due upon invoice receipt from Provider. I must pay charges outstanding within 30 days of the first invoice received.
Should Provider refer my account to a collection agency or attorney for collection, I agree to pay all collection costs allowed by law, including but not limited to court costs and attorney fees of 30% of my bill. I understand that all delinquent accounts shall bear interest at the rate of 12% per annum.
I agree that Provider may contact me via telephone, email, USPS, or text to facilitate my order and payment, remind me about maintenance items, and alert me to new products and promotions.
I have been instructed on the proper and safe use of the above-listed equipment.