Insurance Breast Pump Form

Planning on breast feeding? Insurance may cover the cost of your 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 Maxflow

Medela Pump in Style Maxflow {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smart Pump

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

{binding displayValue}

Lansinoh Signature Pro

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

{binding displayValue}

Spectra 2 Plus

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

{binding displayValue}

Spectra S9

Spectra 9 {{ 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

Vivertiy 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}

Evenflow Double

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

{binding displayValue}

Anthem Blue Cross and Blue Shield - Options

Lansinoh Signature Pro

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 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}

Medela Advanced Personal Backpack

Medela Pump In Style Advanced Backpack

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

{binding displayValue}

Medela Advanced Pump In Style With Tote

Medela Pump In Style Advanced on-the-go Tote

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

{binding displayValue}

Lansinoh Smart Pump

Lansinoh Smart Pump Double Electric

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

{binding displayValue}

Spectra S1

Spectra S1 Plus

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

{binding displayValue}

Spectra S2

Spectra S2 Plus

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

{binding displayValue}

Spectra S9

Spectra 9 Plus

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

{binding displayValue}

Viverity True Ease Single

Vivertiy 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}

Evenflow Double

Evenflow Double Electric

$15.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Maine Community Health Options - Options

Medela Pump in Style Maxflow

$105.00 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}

Medela Advanced Personal Backpack

Medela Pump In Style Advanced Backpack

$200.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Advanced Pump In Style With Tote

Medela Pump In Style Advanced on-the-go Tote

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

{binding displayValue}

Lansinoh Smart Pump

Lansinoh Smart Pump Double Electric

$110.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1

Spectra S1 Plus

$175.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S2

Spectra S2 Plus

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

{binding displayValue}

Spectra S9

Spectra 9 Plus

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

{binding displayValue}

Viverity True Ease Single

Vivertiy 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}

Evenflow Double

EvenFlo Double Electric

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

{binding displayValue}

Harvard Pilgrim Options

Lansinoh Signature Pro

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

{binding displayValue}

Medela Pump in Style Maxflow

Medela Pump in Style 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}

Medela Advanced Personal Backpack

Medela Pump In Style Advanced Backpack

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

{binding displayValue}

Medela Advanced Pump In Style With Tote

Medela Pump In Style Advanced on-the-go Tote

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

{binding displayValue}

Lansinoh Smart Pump

Lansinoh Smart Pump Double Electric

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

{binding displayValue}

Spectra S1

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

{binding displayValue}

Spectra S2 Plus

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

{binding displayValue}

Spectra S9

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

{binding displayValue}

Viverity True Ease Single

Vivertiy 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}

Evenflow Double

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

{binding displayValue}

Aetna Options

Spectra S2

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

{binding displayValue}

Medela Pump in Style Maxflow

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

{binding displayValue}

Lansinoh Signature Pro

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}

Medela Advanced Personal Backpack

Medela Pump In Style Advanced Backpack

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

{binding displayValue}

Medela Advanced Pump In Style With Tote

Medela Pump In Style Advanced on-the-go Tote

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

{binding displayValue}

Lansinoh Smart Pump

Lansinoh Smart Pump Double Electric

$50.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Spectra S1

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

{binding displayValue}

Spectra S9

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

{binding displayValue}

Viverity True Ease Single

Vivertiy 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}

Evenflow Double

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

{binding displayValue}

Qualcare Options

Lansinoh Signature Pro

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

{binding displayValue}

Medela Pump in Style Maxflow

Medela Pump in Style 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}

Medela Advanced Personal Backpack

Medela Pump In Style Advanced Backpack

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

{binding displayValue}

Medela Advanced Pump In Style With Tote

Medela Pump In Style Advanced on-the-go Tote

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

{binding displayValue}

Lansinoh Smart Pump

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

{binding displayValue}

Spectra S1

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

{binding displayValue}

Spectra S2

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

{binding displayValue}

Spectra S9

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

{binding displayValue}

Viverity True Ease Single

Vivertiy 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}

Evenflow Double

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

{binding displayValue}

Martin's Point US Family Health Plan - Options

Medela Pump in Style 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}

Medela Advanced Personal Backpack

Medela Pump In Style Advanced Backpack

$150.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medela Advanced Pump In Style With Tote

Medela Pump In Style Advanced on-the-go Tote

$150.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Lansinoh Smart Pump

Lansinoh Smart Pump Double Electric

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

{binding displayValue}

Spectra S1

Spectra S1 Plus

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

{binding displayValue}

Spectra S2

Spectra S2 Plus

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

{binding displayValue}

Spectra S9

Spectra 9 Plus

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

{binding displayValue}

Viverity True Ease Single

Vivertiy 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}

Evenflow Double

EvenFlo Double Electric

$55.00 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'] }}

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