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Breast Pump Insurance Order Form v.4
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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?
*
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YES
NO
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2
At this time we do not offer Breast Pump's through insurance for the state you are in.
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3
Patient Information
*
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First Name
Last Name
Date of Birth
Phone Number
Street Address
City
State
Zip Code
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4
Email
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example@example.com
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5
Due Date (if expecting) or Date of Baby's Birth (if your little one has already arrived!)
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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
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Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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8
OBGYN/Midwife Information
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OBGYN/Midwife Name
OBGYN/Midwife Phone Number
OBGYN/Midwife Facility Name
OBGYN/Midwife Office Address
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9
Insurance Information
Please Select
Aetna
Allied Benefits
Allways (Commercial)
Allways My Care Family (Medicaid)
Amerihealth Caritas
Anthem Blue Cross Blue Shield of CT
Anthem Blue Cross Blue Shield of ME
Anthem Blue Cross Blue Shield of NH
Blue Cross Blue Shield of MA
Blue Cross Blue Shield of RI
Blue Benefits of MA
Cigna
Cigna Carelink
Commonwealth Care Alliance
CT Medicaid
Fallon (Medicaid)
Fallon Direct
Firefly
GPA Image 360
Harvard Pilgrim Health Plan
Health Plans Inc
HNE Be Healthy
Healthy New England for HMO/PPO
MA Wellsense
Maine Community Health Plan
Mainecare
Masshealth
Mass General Brigham (Commercial)
Mass General Brigham (Medicaid)
New Hamphsire Healthy Families
NH Wellsense
Neighborhood Health Plan (NHP) of RI
Tricare
Tufts
Tufts Health Direct
Tufts Health Together
Tufts Health Unify
Unicare/GIC
United Choice Plus (Harvard Pilgrim Passport Connect Plan)
VT Medicaid
My Insurance Isn't Listed (Please manually enter provider below)
Please Select
Please Select
Aetna
Allied Benefits
Allways (Commercial)
Allways My Care Family (Medicaid)
Amerihealth Caritas
Anthem Blue Cross Blue Shield of CT
Anthem Blue Cross Blue Shield of ME
Anthem Blue Cross Blue Shield of NH
Blue Cross Blue Shield of MA
Blue Cross Blue Shield of RI
Blue Benefits of MA
Cigna
Cigna Carelink
Commonwealth Care Alliance
CT Medicaid
Fallon (Medicaid)
Fallon Direct
Firefly
GPA Image 360
Harvard Pilgrim Health Plan
Health Plans Inc
HNE Be Healthy
Healthy New England for HMO/PPO
MA Wellsense
Maine Community Health Plan
Mainecare
Masshealth
Mass General Brigham (Commercial)
Mass General Brigham (Medicaid)
New Hamphsire Healthy Families
NH Wellsense
Neighborhood Health Plan (NHP) of RI
Tricare
Tufts
Tufts Health Direct
Tufts Health Together
Tufts Health Unify
Unicare/GIC
United Choice Plus (Harvard Pilgrim Passport Connect Plan)
VT Medicaid
My Insurance Isn't Listed (Please manually enter provider below)
Primary Insurance Name
Enter Insurance Provider if Not Listed Above
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
Success! Aetna fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre S6
Zomee Z2 Breast Pump
The Breast Pump I'm interested in is not listed.
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13
Success! Allied Benefits fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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14
Success! AllWays (Commercial) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5 Plus
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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15
Success! AllWays My Care Family (Medicaid) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5 Plus
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
16
Success! Amerihealth Caritas fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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17
Success! Anthem Blue Cross Blue Shield of CT fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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18
Success! Anthem Blue Cross Blue Shield of ME fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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19
Success! Anthem Blue Cross Blue Shield of NH fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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20
Success! Blue Cross Blue Shield of MA fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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21
Success! Blue Cross Blue Shield of RI fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
22
Success! Blue Benefits of MA fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
23
Success! Cigna fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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24
Success! Cigna Carelink fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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25
Success! Commonwealth Care Alliance (CCA) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5 Plus
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Submit
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Enter
26
Success! CT Medicaid fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
27
Success! Fallon Direct fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
28
Success! Fallon Medicaid fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
29
Success! Firefly fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
30
Success! GPA Image 360 fully covers the following pumps
*
This field is required.
Please select from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
31
Success! Harvard Pilgrim Health Plan fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5+
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Submit
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Enter
32
Success! Health Plans Inc fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5+
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
33
Success! HNE Be Healthy fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
34
Success! Health New England for HMO/PPO fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
35
Success! MA Wellsense fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
36
Success! Maine CHO (Community Health Plan) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S6
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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37
Success! Mainecare fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S6
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
38
Success! MassHealth fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5 Plus
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Submit
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Enter
39
Success! Mass General Brigham (Commercial) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5 Plus
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Submit
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Enter
40
Success! Mass General Brigham (Medicaid) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5 Plus
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Next
Submit
Press
Enter
41
Success! New Hampshire Healthy Families fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
42
Success! NH Wellsense fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
43
Success! Neighborhood Health Plan (NHP) of RI fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
44
Success! Tricare fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
45
Success! Tufts fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S6
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Submit
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Enter
46
Success! Tufts Health Direct (Medicaid) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
47
Success! Tufts Health Together fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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48
Success! Tufts Health Unify fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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49
Success! Unicare/GIC fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Enter
50
Success! United Choice Plus (Harvard Pilgrim Passport Connect Plan) fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Cimilre P1
Cimilre S5+
Cimilre S6
Medela Pump in Style
Spectra S2 Plus
Zomee Fit
Zomee Z2
The Breast Pump I'm interested in is not listed.
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Submit
Press
Enter
51
Success! VT Medicaid fully covers the following pumps
*
This field is required.
Please select what you would like to purchase from the following pumps fully covered by your insurance.
Spectra S2 Plus
Zomee Z2
The Breast Pump I'm interested in is not listed.
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52
Select any pumps that you are interested in ordering
*
This field is required.
Product descriptions can be found
here
. We will contact you to complete your order
Cimilre P1
Cimilre S5+
Cimilre S6
Cimilre S6+
Lansinoh Signature Pro
Medela Freestyle Flex
Medela Pump in Style
Medela Pump in Style (upgraded kit)
Spectra S1 Plus
Spectra S2 Plus
Zomee Fit Wearable
Zomee Z2 - Rechargeable
The breast pump I'm interested in is not listed
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53
Please select any additional supplies you'd like to purchase.
*
This field is required.
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.
$69.99 *Spectra CaraCups* Collection cups compatible with all Spectra breast pumps, allowing moms to express breastmilk handsfree.
$59.99 *Zomee Silicone Cups* Breastmilk collection cups designed for busy moms who need an easy and discreet way to pump.
No thanks. I'd only like to order the breast pump.
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54
Thank you for choosing Reliable Maternity! How did you hear about us?
*
This field is required.
Insurance Company
Medical Provider
Word of Mouth
Online Search
Social Media
Other
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55
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
.
Yes
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