By checking the boxes below, I agree to the following:
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.
If for any reason and to any extent, 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. All charges not paid within 45 days of billing date shall incur 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 he/she will provide me with a copy of this completed form for my records.
