Breast Pump Order Form

Insurance & HSA Covered Pumps

Product Order

You may be responsible for any co-payments and/or deductibles that are required by your insurance plan.

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Breast Pumps Order Form

Patient Information

Have you worked with Neb Doctors of MN Before?*

How did you hear about us?*

First

Middle

Last

Date of Birth*

Baby’s DOB/Due Date*

Address*

Street Address

Apartment/Suite

City

State / Province

ZIP / Postal Code

Your Email Address*

Contact Phone Number*

Medical Provider Information

Treating Doctor/Provider Name*

Clinic/Facility Name*

Clinic Location*

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Insurance Information

Primary Insurance Company*

Insurance ID#*

Group#*

Select Your Breast Pump

Do You Have a Prescription?

If ‘Yes’ PLEASE UPLOAD YOUR PRESCRIPTION BELOW or email your prescription to support@nebdr.com.

Prescription Upload:

File Upload

Please use file type of pdf, jpg, or .doc (Microsoft Word). Please make sure your file size is 10 MB or less.

We will contact you by phone, at the contact number provided above prior to processing your order. Orders are processed and shipped/mailed the following business day.

*Note: Charges will be submitted to your health insurance company. The insurance company determines the allowable charge amount for the item(s) and then applies your individual coverage. For example, if your deductible has been met for the year, you will likely not have any out of pocket expense for covered supply items. However, if the deductible has not been met, your insurance company will determine the allowable charges and apply them to your deductible. We will bill you for the portion your insurance company determines is your responsibility.

Comments/Questions

We will contact you via phone prior to shipping your order.