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Breast Pump Insurance Order Form
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HIPAA
Compliance
1
Are you located in one of the following States: Massachusetts, Connecticut, Rhode Island, New Hampshire, Vermont or Maine?
YES
NO
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2
At this time we do not offer Breast Pumpsthrough insurance outside of New England
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3
Patient Information
*
This field is required.
First Name
Last Name
Date of Birth
Phone Number
Street Address
City
State
Zip Code
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4
Email
*
This field is required.
example@example.com
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5
Due Date
*
This field is required.
-
Date
Month
Day
Year
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6
Prescription
*
This field is required.
I have a prescription for an electric breast pump
I do not have a prescription for an electric breast pump
I have a prescription for an electric breast pump
I do not have a prescription for an electric breast pump
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7
Prescription Upload
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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8
OBGYN/Midwife Information
OBGYN/Midwife First and Last Name
OBGYN/Midwife Phone Number
OBGYN/Midwife Facility Name
OBGYN/Midwife Office Address
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9
Insurance Information
Please Select
Aetna
Allways
Anthem BC/BS of CT
Anthem BC/BS of ME
BCBS MA
BCBS of RI
Blue Benefits of Mass
BMC Healthnet/Northwood
Cigna
CT Medicaid
Harvard Pilgrim
Masshealth
Tufts - Commercial
Tufts - Medicaid
Unicare/GIC
VT Medicaid
My Insurance Isn't Listed
Please Select
Please Select
Aetna
Allways
Anthem BC/BS of CT
Anthem BC/BS of ME
BCBS MA
BCBS of RI
Blue Benefits of Mass
BMC Healthnet/Northwood
Cigna
CT Medicaid
Harvard Pilgrim
Masshealth
Tufts - Commercial
Tufts - Medicaid
Unicare/GIC
VT Medicaid
My Insurance Isn't Listed
Primary Insurance Name
Primary Insurance ID#
Please Select
I am the policy holder
I am the spouse of the policy holder
I am the child of the policy holder
Please Select
Please Select
I am the policy holder
I am the spouse of the policy holder
I am the child of the policy holder
Relationship to Policy Holder
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10
Do you have secondary insurance?
*
This field is required.
YES
NO
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11
Secondary Insurance Information
*
This field is required.
Secondary Insurance Name
Secondary Insurance ID#
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12
Select any pumps that you are interested in ordering.
We will contact you to complete the order.
Cimilre P1
Cimilre S5+ - Dual Motor
Cimilre S6
Cimilre S6+
Elve Stride - Wearable
Elvie Pump Double Electric
Lansinoh Smart Pump 2.0
Medela Pump in Style w/ Maxflow
Medela Pump in Style w/ Maxflow (upgraded kit)
Spectra Synergy Gold
Spectra S2+
Spectra S1+ - Rechargeable
Zomee Fit Wearable
Zomee Z2 - Rechargeable, 2-Phase Motor
I'm interested in a pump not listed
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13
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.
$59.99 *Zomee Silicone Cups* Wearable, silicone collection cups for a complete hands-free experience. Designed for busy moms.
$64.99 *Spectra CaraCups* A set of collection cups to place in the bra allowing mom's to express breastmilk handsfree. Designed for use with all Spectra pumps.
No thanks. I'd only like to order the breast pump.
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14
Terms and Conditions Acknowledgment
*
This field is required.
I acknowledge that if I have coverage under more than one 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 understand that if my insurance has already covered a breast pump for this pregnancy, this claim may be denied and I will be responsible for paying the full retail value of the breast pump to Reliable Maternity. I certify that I have reviewed, understand, and accept the terms and conditions disclosed
here
.
YES
NO
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