Insurance Eligibility Check - Military Mommies

Insurance Verification

Now accepting commercial insurance
Have you already submitted this insurance verification form for your current pregnancy?
Please select the person you are working with:*
Patient's Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Email*
example@example.com
Number of weeks pregnant *
Enter 0 if not pregnant
Due Date or Baby's DOB *

MonthDayYear
Enter Baby's DOB is not currently pregnant
Primary Insurance: *
Primary Insurance ID Number*
(If TRICARE enter Sponsor's Social Security Number)
Secondary Insurance
Secondary Insurance ID Number
Patient's Social Security Number*
Your Social Security Number
Benefit Number*
(If TRICARE enter 11-digit number on back of military ID at the top)
Primary Phone*
Secondary Phone
Billing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Product(s) Requested (check all that apply):*

Double Electric Breast Pump/Access. - E0603 (A4283,A4284,A4285,A4286,K1005, A4281)Embracing Belly Boostier, Lumbar Support/Back support - L0621Mama Strut - L8310Abdominal Ice/Heat pack (additional, not covered by insurance) - A9273Lower Back Ice/Heat pack (additional, not covered by insurance) - A9273Pelvic Control Band, Belt (Motif) - L2630Compression Garment (knee high stocking, thigh high stocking, pantyhose)
Breast Pump Survey*
Please select the pump you already have in mind:*

*This selection is for Area Partner Knowledge only and does not constitute an official order*Ameda Mya Joy PlusElvie StrideLansinoh Smart Pump 2.0Motif DuoMotif LunaSpectra S1Unimom MinuetUnimom OperaSpectra S9Baby BuddhaMedela Pump In Style MaxflowSpectra Synergy Gold OriginalSpectra Synergy Gold PortableMedela Freestyle Hands FreeZomee FitZomee Z2
Prescription Status*
Attach a copy of your prescription

Browse Files
Prescription should state: “Double Electronic Breast Pump & Supplies” Cancelof
Physician's Order & Letter of Medical Necessity

Breast Pumps & Accessories, Pregnancy & Postpartum, Compression
After completing this form YOU WILL RECEIVE A PDF All-In-One Prescription form for you to take to your physician's office to be signed. If you would like us to fax the form on your behalf, please check YES to the corresponding question below.

PLEASE NOTE: THIS FILLABLE PAGE CANNOT AND SHOULD NOT BE PRINTED AS THE PRESCRIPTION. PLEASE USE THE PDF YOU RECEIVE UPON SUBMISSION FOR VALIDATION PURPOSES.
Do you want us to fax the prescription to your physician for you?*

YesNo
Diagnosis Z39.1 and Length of Need Birth Event or 36 months, unless otherwise noted*

EGA:________weeks
Pregnancy Support Diagnosis Code(s):

M54.50, Lower back painOther __________________
Postpartum Diagnosis Code(s):

R10.2, Pelvic and perineal painOther ___________________
Compression, DX:I87.2 or other:______________

Physician, please select required garment belowA6530 - Knee-high 15-20mmHgA6530 - Knee-high 20-30mmHgA6531 - Knee-high 30-40mmHgA6533 - Thigh-high 15-20mmHgA6533 - Thigh-high 20-30mmHgA6534 - Thigh-high 30-40mmHgA6539 - Pantyhose 15-20mmHgA6539 - Pantyhose 20-30mmHgA6540 - Pantyhose 30-40mmHg
Please indicate the style and compression being ordered:

Style:_________________ (knee-hi, thigh-hi, or pantyhose)

Compression: _______________mmHg (15-20, 20-30, or 30-40)

Number of pairs: _______ pairs
Physician's Name*

First NameLast Name
Physician's Phone #*
Valid number must be submitted.
Physician's Fax #*
If a valid phone number AND fax number are not submitted the form will be voided and not faxed.
Physician:*

I prescribe a double electric breast pump (E0603) and the following breast pumps accessories: Replacement Tubing For Breast Pump (A4281); Replacement Breast Pump Adapters (A4282); Replacement Caps For Breast Pump Bottles (A4283); Replacement Shields And Splash Protectors For Breast Pump (A4284); Replacement Bottles For Breast Pump (A4285); Replacement Rings For Breast Pump Bottles (A4286); Storage Bags For Breast Milk (K1005); Breast Pump Valves and Membranes(A4281).
By my signature below, I certify the patient, being treated by me, has the above diagnosis and I have prescribed breast pump(s) and supplies for lactation and breast feeding. It is my expert opinion that the prescribed products and supplies are medically necessary to facilitate management of the patient’s condition. This prescription shall also serve as the Letter of Medical Necessity and all the information contained on this document accurately reflects the patient’s condition and the treatment regimen that I have prescribed. The medical records for this patient substantiate the diagnosis for prescribed devices. The patient is able to follow instructions for managing lactation and is capable of using the ordered items. For insurance requirements, I agree to maintain this signed original document in the patient’s medical record file for post-payment review/audit purposes. I certify, if I am a non-physician healthcare provider, that I have all necessary licensure and authorization under applicable state and federal law to treat this patient for her condition and to prescribe the above equipment and/ or supplies. I further certify that: (i) I have spoken with the patient and discussed the products and services that Barber DME and/or any of their corporate affliates offer; (ii) the patient has authorized me, as her agent and representative, to authorize Barber DME to contact the patient by phone to discuss products and services that Barber DME offers and which may be available to such patient; and, (iii) as the patient’s authorized agent and representative, I hereby authorize Barber DME to contact the patient by phone for such purposes.

Physician's Signature ___________________Physician's NPI:_______________Date: _____________

This document is not intended to be a substitute for the comprehensive medical record. Per Medicare guidelines, this form must be supported with information in the format used for other chart entries.

Fax back to our eFax: 866-651-6040
Financial Responsibility Statement

By signing below, I acknowledge that I have provided Barber DME Supply Group, LLC with my accurate insurance information and I authorize the use of my insurance information to be used to bill for Services Rendered. I understand that Barber DME Supply Group, LLC will release the stated item(s) to me in good condition with the full intent to bill my insurance(s). I understand that I may be financially responsible and may be billed by Barber DME Supply Group, LLC for any costs my insurance(s) will not cover. I also understand that I may not be permitted to return certain item(s) for payment.

I understand that the Durable Medical Equipment (DME) being provided to me by Barber DME Supply Group, will be billed to my medical insurance carrier. I further understand that the DME provided could be subject to a co-share/co-payment or if my annual deductible has not been met, a payment of deductible. In the event of any payment due on my part, I agree to make such payment to Barber DME Supply Group within 21 days of the invoice date. If the following below are being provided, Barber DME Supply Group agrees to set a ceiling to any co-pay amount to a maximum payment for the item(s) listed.

HIPAA Statement

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical information and individually identifiable health information used or disclosed by us in any form, electronic, paper or orally are kept properly confidential. This Act gives you, the patient significant new rights to understand and control how your health information is used.

We may use and disclose your records for each of the following purposes: Treatment, Payment and Healthcare Operations (Definitions are available upon request)

We may contact you about supply alternatives, other health related benefits and services that may be of interest. We may disclose medical information to family members or caregivers. We may disclose medical information when required to do so by federal, state or local law or to an oversight agency for activities authorized by law.

Any other uses or disclosures will be made only with your written authorization. You may revoke such authorization and we are required to honor and abide by that written consent. You have rights with respects to your protected Health Information. We are required by law to maintain the privacy of your protected health information and provide to you with notice of our legal duties and privacy practices with respects to protected health information.

This notice takes effect immediately and we are required to abide to the terms of this privacy notice. You have recourse if you feel your privacy protections have been violated. You have the right to file a written complaint with our office or the Department of Health and Human Services.

Personal Care/Custom-made Items

I understand that the item(s)/product(s) that are personal care items and for hygienic reasons cannot be returned for any reason once opened. I understand that these products are non-returnable, non-refundable, or exchangeable. I am fully aware that custom-made items are custom-made using the measurements from my physician/nurse/medical professional who is not with Barber D.M.E. Supply Group, LLC. Therefore, I understand that Barber DME is not liable for any incorrect measurements and I may have to pay shipping fees for returned items due to incorrect measurements. Return decisions are up to the discretion of the warehouse team. Additionally, I must reach out to Military Mommies to return any unopened items and a return label will be provided; If I do not use the provided return label from Military Mommies and Barber DME, I am responsible for all shipping charges for items.
Verification*

I have read and acknowledged the above Financial Responsibility Statement, HIPAA Statement, and Personal Care/Custom-made Items policy.
Name of person completing this form*
Relationship to Beneficiary*
Signature*

Clear
Date*

MonthDayYear
Date
For questions and/or concerns, email:
Military Mommies Customer Service
PLEASE NOTE YOU MAY RECEIVE A SERVER ERROR AFTER SUBMISSION.

YOUR INFORMATION WAS STILL SUBMITTED AND A REPRESENTATIVE WILL REACH OUT TO YOU.
Should be Empty:

Insurance Verification

Physician's Order & Letter of Medical Necessity

PLEASE NOTE YOU MAY RECEIVE A SERVER ERROR AFTER SUBMISSION.

YOUR INFORMATION WAS STILL SUBMITTED AND A REPRESENTATIVE WILL REACH OUT TO YOU.