Breast Pump Insurance form for Illinois

1
Patient's Name* This field is required.Expecting Mother's Name
First Name
Last Name
2
Expected Due DateBreast Pumps can be dispensed starting at the 28th week of pregnancy
Date
Month
Day
Year
3
Shipping Address* This field is required.Illinois only
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
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El Salvador
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Eritrea
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Ethiopia
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Faroe Islands
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The Gambia
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Iran
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Laos
Latvia
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Lesotho
Liberia
Libya
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Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.Mobile number
We will text you updates
5
Email* This field is required.Internal use only
example@example.com
6
Date of Birth* This field is required.MM-DD-YYYY
Date
Month
Day
Year
7
Emergency ContactYou can always put yourself
Contact Name
Contact's mobile number
Contact's Relationship to you
8
Insurance Policy Name* This field is required.Select from drop down
Aetna Medicaid of Illinois
Blue Cross Blue Shield of Illinois
Blue Cross Blue Shield-Medicaid
County Care
Illinois Public Aid
Meridian Health
9
Policy Number* This field is required.
Member ID
10
Group NoNot applicable to medicaid insurance
Required for BCBS commercial policy
11
Prescribing Provider* This field is required.Doctor or Midwife Information Who is writing the Prescription?
Full Name
Office ☎️
Office Fax
12
Do you have a prescription already?* This field is required.If No, don't worry a fax request will be sent
YESNO
13
Upload prescription image 📷Skip to next, if you don't have an RX
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Insurance forgets to tell you its required for us to bill
Cancelof
14
Insurance Card Front image
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Make sure it's legible
Cancelof
15
Government ID* This field is required.Driver's license/ Passport/State license
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Browse Files
Your photo is better than mine required
Cancelof
16
Enter the COUPON CODE according to your insurance carrier policy:

1. BCBSPPO- Blue Cross Blue Shield PPO (max coverage is $150)

2. MEDICAID -Medicaid, Aetna Better Health Medicaid, Blue Cross Blue Shield MMCP, County Care, Meridian Health Plan MMCP, Molina Health Care (max coverage is $139.00)

The field will appear at the bottom of the breast pump list in the next section.

If you have MEDICAID you are NOT eligible to pay the difference between an upgraded model
17
Breast Pump Options* This field is required.Enter Coupon Code: BCBSPPO or MEDICAID accordingly
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My Bag
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My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
ShippingUSD
SubtotalUSD
Total costUSD
Zomee Z2 with Tote
Default option for Medicaid policies. AAMS FAVORITE
$139.00Edit
Back
Tote included
Tote included
No Tote needed
Bag option
Medela Pump in Style with Max Flow
Covered under BCBS PPO
$150.00Edit
Back
S1 Plus Portable & Rechargeable
Upgrade Model for BCBS PPO
$216.00Edit
Back
S1Plus with Deluxe Tote
*Most popular upgraded item for BCBS PPO* Spectra S1 soft blue electric breast pump TOTEl, ZGrey, Cooler Bag Pink .Max Suction Strength: 270 mmHgPump Noise Level: 45 dB
$260.00Edit
Back
S2 Plus by Spectra
Covered under BCBS PPO
$150.00Edit
Back
S9 Plus by Spectra
Covered under BCBS PPO
$150.00Edit
Back
Baby Buddha
Upgrade Model for BCBS PPO
$250.00Edit
Back
Zomee Fit Wearable Double Electric
Worn inside your bra. Silent. Hands-Free. Comfortable.Now you can have it all – a Zomee hospital-grade strength motor in a wearable pump! Thoughtfully designed for quick and effective expression with Zomee's hands-free wearable pumps. Rechargeable for hours of use and easy-to-use technology that doesn’t require an app.
$249.99Edit
Back
Elvie
BCBS PPO UPGRADE * Silent and Wearable
$549.99Edit
Back
MOTIF LUNA with battery
Sophisticated, strong, and soothing. The Luna is the powerful breast pump from Motif Medical, built for modern motherhood and proven to provide More Milk in Less Time®. With a battery-powered or non-battery version, the Luna is perfect for today’s busy mom
$189.00Edit
Back
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Quantity
Elvie Stride
Hospital-grade performance, now hands-free (5oz/150 ml) With portable hospital-grade performance, Elvie Stride frees you to express efficiently wherever you please. No dangling bottles or balancing acts, Elvie Stride offers power and comfort — all while keeping your hands free.
$269.99Edit
Back
Evenflo Advanced Double Electric
no tote
$150.00Edit
Back
Freemie
$150.00Edit
Back
Enter Coupon
Total cost $0.00
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Invoice ID
19
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Breast Pump Upgrade Charge Waiver and Disclaimer

I understand if I request an upgrade to a breast pump model that exceeds my insurance coverage. I agree to pay the difference in cost before receiving the upgraded pump.

Commercial Insurance: My insurance covers up to $150.00 for a breast pump. I can receive it up to 6 weeks before my estimated delivery date.

Medicaid/MCO Insurance: My insurance covers one breast pump for up to $120.00 or less every 367 days. I am not able to pay for an upgrade. I may choose to purchase accessories on my own. I must have given birth to receive the pump. I acknowledge that I am responsible for any charges exceeding my insurance coverage. I have been informed of the upgrade options and their associated costs.

By submitting the order and waiver, I release All American Medical Supply from any liability related to the upgrade charges and will inform them of my deposition accurately.
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Signature
Should be Empty: