Breast Pump Insurance Order Form

1
Are you located in one of the following States: Massachusetts, Connecticut, Rhode Island, New Hampshire, Vermont or Maine?* This field is required.
YESNO
2
At this time we do not offer Breast Pump's through insurance for the state you are in.
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 (if expecting) or Date of Baby's Birth (if your little one has already arrived!)* 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
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Prescription Upload* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Provider Information* This field is required.
Provider First Name
Provider Last Name
Provider Facility Name
Provider Office Address
Provider Phone Number
9
Insurance Information
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
Enter Primary Insurance ID#
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
10
Do you have secondary insurance?* This field is required.
YESNO
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Secondary Insurance Information* This field is required.
Secondary Insurance Name
Secondary Insurance ID #
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Our most popular pump is the Zomee Z2

This pump is fully covered by your insurance and is shipped for free!

3 different pumping styles that you can further tailor for comfort: Massage, Expression, and 2-Phase mode (expression and massage)

Portable, lightweight, and hospital grade strength

The back-lit display is easy to read and convenient for low light conditions

A hygienic closed system helps prevent milk backup into tubing for easier cleanup

A durable Lithium battery and a Micro USB port with a standard USB cable for connecting to a power source make Zomee ideal for working or traveling mothers

To make Zomee Z2 hands-free, Zomee Collection Cups can be purchased separately.
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Success! Your insurance fully covers the following pump:* This field is required.Please make a selection based on the options below.
Zomee Z2
The Breast Pump I'm interested in is not listed.
14
What pump are you interested in purchasing?* This field is required.Please select what you would like to purchase from the following options. Our team will check with your insurance coverage based on your selection.
Zomee Z2
The Breast Pump I'm interested in is not listed.
15
Enter the pump that you are interested in ordering* This field is required.Product descriptions can be found here. We will contact you to complete your order
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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.
$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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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
18
Please verify that you are human* This field is required.
19
Terms and Conditions AcknowledgmentI 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
20
By submitting this form you are agreeing to the terms below* This field is required.1. Medical Information Authorization: Customer authorizes any holder of medical information relating to said Customer to release to Reliable Respiratory any record pertaining to his or her medical history, services rendered, or treatment. Customer authorizes Reliable Respiratory to release Customer’s medical information to appropriate accreditation and insurance company personnel and other health care related organizations. Customer authorizes use of email to communicate with these organizations. 2. Financial Responsibility and Communications Consent: Customer understands that insurance coverage is not guaranteed and remains responsible for all amounts not paid by insurance, including denied claims, copayments, deductibles, coinsurance, and other non-covered charges. Customer authorizes Reliable Respiratory to charge the credit card on file for such amounts. Any balance that remains unpaid more than fourteen (14) days after the due date may be subject to collection efforts, and Reliable Respiratory may require the return of equipment until the account is paid in full. 3. Customer also authorizes Reliable Respiratory and its service providers to contact Customer by non-automated, automated, or AI-assisted calls, text messages, emails, and other digital communication channels regarding care, therapy, resupply, scheduling, billing, payment, and provider coordination. Calls may be recorded. Consent to receive such communications is not a condition of receiving care or services. Message and data rates may apply. Customer may opt out of marketing or non-essential communications at any time by replying STOP, using an unsubscribe option, or contacting Reliable Respiratory. 4. Assignment of Insurance Benefits: Customer authorizes any and all Medicare, Medicaid, or other insurance benefits to be paid directly to Reliable Respiratory for any equipment or services furnished to Customer by Reliable Respiratory.
Electronic Signature
Date Signed
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