Eligibility - Military Mommies

Name of Military Mommies Partner Who Assisted You:*

First NameLast Name

Name of Military Mommies Partner Who Assisted You:*

Client’s Name*

First NameMiddle NameLast Name

Client's Date of Birth*

Date

Due Date*

Date

Primary Insurance*

Primary Insurance Number/SSN

Secondary Insurance

Secondary Insurance Number

Benefit Number*

11-digit number on back of military ID

Billing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Shipping Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Email*

example@example.com

Primary Phone*

Phone*

Secondary Number

Secondary Number*

Secondary Phone

Phone

Product Interest

Pump Selection:

Pregnancy & Postpartum Support (Select all that apply)

Embracing Belly Boostier (Pregnancy)Mama Strut (Postpartum)Motif (Postpartum)Type option 4

Prescription Status*

Already have a prescription (attach below)I will obtain a prescription from my physician (product orders will not be processed without it)Obtain a prescription from my physician on my behalf (Please fill out the Prescription Request Form at the link provided in your submission confirmation and provide your Physician's information below.)

Physician's Name

First NameLast Name

Physician's Phone Number

Physician's Fax Number

Attach a copy of your prescription

Browse Files

Prescription should state: “Double Electronic Breast Pump & Supplies”

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, nor 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 for shipping fees for returned items due to incorrect measurements.

Verification*

I have read and acknowledged the above Financial Responsibility Statement, HIPAA Statement, and Personal Care/Custom-made Items policy.

I have received a copy of the Medicare Supplier Standards (if applicable)*

YesNoN/A

Name of person completing this form*

Relationship to Beneficiary*

Signature*

Date*

Date

For questions and/or concerns, email:*

Military Mommies Customer Service

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