Breast Pump Insurance Order Form v.2

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 Pumpsthrough insurance outside of New England
3
Patient Information* This field is required.
First Name
Last Name
Date of Birth
Phone Number
Street Address
City
State
Zip Code
4
Email* This field is required.
example@example.com
5
Due Date* This field is required.
Date
Month
Day
Year
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
7
Prescription Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
8
OBGYN/Midwife Information
OBGYN/Midwife Name
OBGYN/Midwife Phone Number
OBGYN/Midwife Facility Name
OBGYN/Midwife Office Address
9
Insurance Information
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#
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
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#
12
Select any pumps that you are interested in ordering. We will contact you to complete the order.
Zomee Z2 - Rechargeable, 2-Phase Motor
Lansinoh Smart Pump 2.0
Elve Stride - Wearable
Ameda Mya Joy
Spectra S2+ -
Spectra S1+ - Rechargeable
Ameda Mya Joy+ - Rechargeable
Cimilre S5+ - Dual Motor
Medela Pump in Style w/ Maxflow
I'm interested in a pump not listed
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.
$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.
14
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 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.
YESNO
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