Breast Pump Insurance Order Form

1

Are you located in one of the following States: Massachusetts, Connecticut, Rhode Island, New Hampshire, Vermont or Maine?

YESNO

2

At this time we do not offer Breast Pump's through insurance for the state you are in.

3

Patient Information* This field is required.

First Name

Last Name

Date of Birth

Phone Number

Street Address

City

State

Zip Code

4

Email

example@example.com

5

Due Date* This field is required.

Date

6

Prescription* This field is required.

7

Prescription Upload* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

8

OBGYN/Midwife Information

OBGYN/Midwife Name

OBGYN/Midwife Phone Number

OBGYN/Midwife Facility Name

OBGYN/Midwife Office Address

9

Insurance Information

Primary Insurance Name

Primary Insurance ID#

Relationship to Policy Holder

10

Do you have secondary insurance?* This field is required.

YESNO

11

Secondary Insurance Information* This field is required.

Secondary Insurance Name

Secondary Insurance ID#

18

Products - BMC Healthnet/Northwood* This field is required.

$0 - Spectra S2 Plus

$0 - Pump In Style® with MaxFlow™ Insurance

$0 - Ameda Mya Joy

$0 - Ameda Mya Rechargeable

21

Products - Masshealth* This field is required.

$0 - Spectra S2 Plus

$0 - Pump In Style® with MaxFlow™ Insurance

$0 - Ameda Mya Joy

$0 - Ameda Mya Rechargeable

22

Products - Tufts - Commercial* This field is required.

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

$25 - Spectra S1 Plus Electric Breast Pump

$50 - Pump In Style® with MaxFlow™ Breast Pump

$100 - Freestyle Flex™ Double Electric Breast Pump

The Breast Pump I'm interested in is not listed.

23

Products - Tufts - Medicaid r* This field is required.

$0 - Spectra S2 Plus Electric Breast Pump

$0 - Pump In Style® with MaxFlow™ Insurance Breast Pump

$0 - Ameda Mya Joy Double Electric Breast Pump

$0 - Ameda Mya Rechargeable

24

Please select any additional supplies you'd like to purchase.Please note, these items would be an out of pocket expense.

$34.99 *Elvie Catch* A set of breast milk collection cups with slip-proof security. Stay leak-free and save your milk.

$49.99 *Elvie Curve* A wearable, silicone breast pump for easy, hands-free expression. Uses natural suction for low-effort expression.

$199.00 *Elvie Trainer* Smart Kegel trainer to strengthen your pelvic floor. Fun, expert-designed workouts and fast results. Your most personal trainer.

No thanks. I'd only like to order the breast pump.

25

Terms and Conditions Acknowledgment* This field is required.I acknowledge that if I have coverage under more than insurance policy, I have listed both insurances in the proper Primary and Secondary insurance sections. If I do not, I may be responsible for payment in full if my claim is denied by the listed Primary insurer. I certify that I have reviewed, understand, and accept the terms and conditions disclosed here.

YESNO