Lactation and Doula Services - Military Mommies

Lactation & Doula Request

To learn more about our Lactation Consultants, Certified Doulas, & the services they provide please visit our website www.militarymommies.com
Please select the provider you would like to work with:*
Will you be using your insurance or paying out of pocket?*
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
What services are you interested in?*
Financial Responsibility Statement

By signing below, I acknowledge that I have provided Barber DME Supply Group, LLC with my accurate insurance information and authorize using my insurance information to bill for Services Rendered. I understand that Barber DME Supply Group, LLC will release this information to one of the practicing professionals with the intent to bill my insurance(s). I understand that I may be financially responsible and may be billed by Barber DME Supply Group, LLC or practiing professionals for any costs my insurance(s) will not cover.

I understand that the medical services chosen above will be billed to my medical insurance carrier. I further understand that the services 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 amount due on my part, I agree to make such payment diresctly to said practicing professional within 21 days of the invoice date.

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 concerning 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.
Verification*

I have read and acknowledged the above Financial Responsibility Statement and HIPAA Statements policy.
Signature*

Clear
Name of person completing this form*
Date*

MonthDayYear
Date
For questions and/or concerns, email:
Military Mommies Customer Service
Should be Empty:

Lactation & Doula Request