CUSTOMER AGREEMENT

• 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 other 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 Pumps for Mom by Neb Doctors (Pumps for Mom) for charges not paid in full by insurance coverage, deductible or co-pay responsibilities or, in the absence of insurance coverage, the full balance. The portions of any bill for which I am responsible are due upon invoice receipt from Pumps for Mom. I must pay charges outstanding within 30 days of the first invoice received. Should Pumps for Mom refer my account to a collection agency or attorney for collection, I agree to pay all collection costs, 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 charge of 12% per annum. The usual and customary prices for the above listed product(s) are not to exceed ($399.00 Electric Pump, $59.00 Manual Pump, $65.00 Canister Supplies). I certify that I have read the terms and conditions of this agreement with the attachments listed above, and agree to its content. I have also been instructed on the proper and Patient received privacy policy.