Insurance Breast Pump Form

Planning on breast feeding? Insurance may cover some or all of the cost of a new breast pump. Fill out this short questionnaire to see if you qualify. Bedard is here to answer any questions you may have.

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}

{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{binding Name}:	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

I acknowledge that I have not received a breast pump through Mainecare for this year. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Baby Due Date or Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I acknowledge I have not received a personal use breast pump through this insurance policy or any other insurance policy for this pregnancy. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Model Interested in? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Yay! MaineCare completely covers the following breast pumps. Make your selection! We also offer free shipping.

Medela Pump In Style with MaxFlow {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Signature Pro {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity Tru Comfort Deluxe Double Electric

Viverity Tru Comfort {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

Ameda Finesse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Anthem Blue Cross and Blue Shield - Options

Lansinoh Signature Pro {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

$20 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Pump In Style with MaxFlow

$80 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Freestyle

Medela Freestyle Double Electric

$230 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric

$20 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus

$130 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus Premier Bundle

$160 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus

$60 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle

$90 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus

$50 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle

$60 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra Synergy Gold

$200 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

$40 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric

$15 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Maine Community Health Options - Options

Medela Pump In Style with MaxFlow

$105 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Freestyle

Medela Freestyle Double Electric

$250.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric

$40 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus

$175 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus Premier Bundle

$200 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus

$95 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle

$125 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus

$60 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle

$75 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra Synergy Gold

$225.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

$60.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric

$40.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Harvard Pilgrim Options

Lansinoh Signature Pro - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Pump In Style with MaxFlow - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Freestyle

Medela Freestyle Double Electric

$105.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus Premier Bundle

$50 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra Synergy Gold

$50 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

Ameda Finesse - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Aetna Options

Spectra S2 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle

$40 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Pump In Style with MaxFlow - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Signature Pro $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Freestyle

Medela Freestyle Double Electric

$195.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus

$75.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus Premier Bundle

$100 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra Synergy Gold

$125 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

Ameda Finesse - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Qualcare Options

Lansinoh Signature Pro - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Pump In Style with MaxFlow - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Freestyle

Medela Freestyle Double Electric

$95.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus Premier Bundle

$30 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra Synergy Gold

$50 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

Ameda Finesse - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric

$30.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Martin's Point US Family Health Plan - Options

Medela Pump In Style with MaxFlow

$80.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Freestyle

Medela Freestyle Double Electric

$160.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smartpump 2.0 Double Electric

$65.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus

$100.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1 Plus Premier Bundle

$150 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus

$55.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2 Plus Premier Bundle

$95 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus

$65.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra 9 Plus Premier Bundle

$95 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra Synergy Gold

$180 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Viverity True Ease Single

Viverity Tru Ease Single Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ameda Finesse

$45.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Evenflo Advanced Double Electric

$70.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Your Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Your Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Height {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Weight (Not Required) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Can we email you about your order? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I have a prescription for an electric breast pump (We'll contact your physician to attain one, if no) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please Upload Prescription {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Physician Information

Physician Name* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Prescribing Physician Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Physician Practice Name* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City of Physician Practice* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emergency Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Newsletter Signup? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name (We'd like to thank them!) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Insurance Group # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payer ID # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

OR Upload Picture of Insurance Card (Not Required) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Spectra Pump Specific Addons {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{{ ['Portable Vehicle Adapter - $14.99','Wide Breast Shield Set Medium 24mm - $24.20','Wide Breast Shield Set XL 32mm - $24.20','Replacement Tubing - $5.99'][$index] }}

MaineCare may cover milk storage bags, would you like some included in your order if approved? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I have viewed Bedard Medical Supplies Privacy and HIPPA Policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Our Privacy Policy and HIPPA Policy

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Insurance Breast Pump Form

Yay! MaineCare completely covers the following breast pumps. Make your selection! We also offer free shipping.

Anthem Blue Cross and Blue Shield - Options

Maine Community Health Options - Options

Harvard Pilgrim Options

Aetna Options

Qualcare Options

Martin's Point US Family Health Plan - Options

Physician Information

{~ Payment_Block_Label}

Insurance Breast Pump Form

{{ Cognito.resources['order-transaction-details-header'] }}

Your progress has been saved.

Insurance Breast Pump Form

{{ Cognito.resources['order-transaction-details-header'] }}

Yay! MaineCare completely covers the following breast pumps. Make your selection! We also offer free shipping.

Anthem Blue Cross and Blue Shield - Options

Maine Community Health Options - Options

Harvard Pilgrim Options

Aetna Options

Qualcare Options

Martin's Point US Family Health Plan - Options

Physician Information