Breastfeeding Pump Order Info

Breastfeeding-pump

Product & Suppply Order

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

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Patient Information

Have you worked with Neb Doctors of MN Before?*

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How did you hear about us?*

First

Middle

Last

Date of Birth*

Baby’s DOB/Due Date*

Address

Address Line 2

State / Province

ZIP / Postal Code

Country

Your Email Addres*

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

Country

Insurance Information

Primary Insurance Company*

Insurance ID#*

Group#*

Do You Have a Prescription?

If ‘Yes’ PLEASE UPLOAD YOUR PRESCRIPTION BELOW or email your prescription to Neb Doctors of MN.

Prescription Upload:

File Upload

Please use file type of pdf, jpg, or .doc (Microsoft Word). Please make sure your file size is 1 MB or less.

Orders are processed and shipped/mailed the following business day. We will contact you by phone, at the contact number provided above, if we are unable to process the order or if we require additional information.

*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

Would you like to be contacted via telephone prior to the processing of your order?*