By checking the boxes below, I agree to the following:
Breast Pumps can not be returned once purchased. Please save this receipt for your records.
I authorize NU-LIFE Medical Equipment and Supplies, Inc. to provide me medical equipment and supplies. I hereby assign all benefits and payments made directly to NU-LIFE Medical Equipment and Supplies, Inc for any home medical, supplies, and services furnished to me in conjunction with my medical needs. It is understood that, as a courtesy, NU-LIFE Medical Equipment and Supplies, Inc. Will bill my insurers providing coverage. Any changes in the insurance policy must be reported to NU-LIFE Medical Equipment and Supplies, Inc. within 7 days of the event.
I have been informed by NU-LIFE Medical Equipment and Supplies, Inc. of the medical necessity for the services. I understand that in the event services are deemed not reasonable and necessary, payment may be denied and that I will be fully responsible for the payment. I hereby request and authorize NU-LIFE Medical Equipment and Supplies, Inc. my physician, hospital, and other holder of information relevant to the service, to release information upon request, to NU-LIFE Medical Equipment and Supplies, Inc. and assigned Business Associate including Medequip Inc. any payer source, physician, or any other medical personal or agency involved with services. I also authorize NU-LIFE Medical Equipment and Supplies, Inc. to review medical history and payer information for the purposes of providing the products & supplies.
I understand and agree that I am responsible for the payment of any and all sums that may become due for the services provided. These sums include, but not limited to all deductibles, co-payments, out of pocket requirements, and non-covered services as determined by the payer/insurer. If for any reason and to any extend, NU-LIFE Medical Equipment and Supplies, Inc. does not receive payment from any payer source, I hereby agree to pay NU-LIFE Medical Equipment and Supplies, Inc. for the balance in full, within 30 days of receipt of invoice. I authorize Nu-life Medical Equipment and Supplies to charge my credit card used for upgrade to pay the balance that insurance does not pay. All charges not paid within 45 days of billing date shall be assessed late charges. I AM RESPONSIBLE FOR ALL CHARGES REGARDLESS OF MY PAYER unless my agreement with my health plan holds me harmless. Returns: Breast pumps cannot be returned. For problems with the unit, please call the manufacturer.
In choosing to upgrade to a deluxe item, I understand that I am responsible for the difference in cost between the retail price of the deluxe item and the retail price of the standard item, plus any applicable deductible and/or copayment and/or coinsurance. Before I signed this document, the durable medical equipment provider completed the information in the box above and has discussed with me all additional costs for choosing to upgrade to a deluxe item. The provider also explained that I shall keep a copy of this completed form for my records. If I choose an upgrade to a deluxe item, I will pay the difference by: Calling 585.672.5105 with a credit card or pay online with Google pay, Apple pay, or Venmo.
