This AOB form is required to bill on your behalf. 1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to Milk Moms, Inc for medical supplies furnished to me by Milk Moms, Inc. 2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurance(s). 3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurance and their agents and assigns. 4. Milk Moms, Inc to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided. 5. Milk Moms, Inc to contact me by telephone or mail regarding my medical supplies and/or medication(s) order. I agree to pay all amounts that are not covered by my insurance including applicable co-payments and/or deductibles for which I am responsible. I request that payment of Medicare, Medicare, Medicaid, Medicare Supplemental or other insurance benefits be made on my behalf to Milk Moms, Inc for any medical supplies and/or medications furnished to me by Milk Moms, Inc. I authorize any holder of medical information about me to release to Milk Moms, Inc, my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurance any information needed to determine or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurance(s) and for which I am responsible. I agree to pay all amounts that are not covered by my insurance including applicable co-payments and/or deductibles for which I am responsible. Deductible amount to be patient’s responsibility of up to $2.65 for Minnesota Medicaid recipients. I understand and agree that if I am choosing to upgrade the ‘basic/standard’ model covered by insurance to a more expensive model, that I am responsible for the additional charges and that it is not a provider write off but a product upgrade charge and agree to pay the additional cost.