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  • Confidential Patient Information

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  • Insurance Information

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    • I authorize Help To Moms to contact me by email, phone or SMS. Help To Moms will not share or distribute this information. By checking this box, I confirm that I have not ordered another insurance-covered breast pump for this pregnancy. I also agree to Help To Mom’s Terms & Conditions  
    • TERMS AND CONDITIONS 

       

    • I do accept the Authorization to Release Information  
    • Disclosures


      Authorization to Release Information
      I hereby authorize AAA DME LLC DBA Music City Med LLC to: (1) release any information necessary to my health
      benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance
      claims generated in the
      course of examination or treatment; and (3) allow a photocopy of my signature to be used to process
      insurance claims. This order will remain in effect until revoked by me in writing.


      ERISA Authorization
      I hereby designate, authorize, and convey to AAA DME LLC DBA Music City Med LLC LLC. To the full extent
      permissible under law and under any applicable
      insurance policy and/or employee health care benefit plan: (1) the right and ability to act on my
      behalf in connection with any claim, right, or cause in action that I may have under such insurance
      policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim,
      right, or cause of action in connection with said insurance policy and/or benefit plan (including
      but not limited to, the right to act on my behalf in respect to a benefit plan governed by the
      provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare
      expense incurred as a result of the services I received from AAA DME LLC DBA Music City Med LLC and, to the
      extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement,
      and any other applicable remedy, including fines.

      A photocopy of this Assignment/Authorization shall be as effective and valid as the original.
      Signature of Policyholder / Insured Date

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