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A Medical Supply Inc. 16 Hayes Ct. Unit 112 Monroe NY, 10950 P: 845-783-6678 F: 888-877-7765 email@example.com
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I acknowledge I have not received a personal use breast pump through this insurance policy or any other insurance policy for this pregnancy. I understand if I have received a breast pump through another provider or insurance coverage this claim may be denied and I will be responsible for paying the full retail value of the breast pump to A Medical Supply Inc.
I agree to HIPPA agreement.