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

Please make sure you only select one.

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Lansinoh Signature Pro

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Spectra S9

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Viverity Tru Comfort Deluxe Double Electric

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Viverity True Ease Single

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Ameda Finesse

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Anthem Blue Cross and Blue Shield - Options

Please select only one.

Lansinoh Signature Pro

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Medela Pump In Style with MaxFlow

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Medela Freestyle

Medela Freestyle Double Electric

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Lansinoh Smartpump 2.0 Double Electric

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Spectra S1 Plus

 

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Spectra S2 Plus

 

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Spectra S9

Spectra 9 Plus

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Viverity True Ease Single

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Ameda Finesse

Ameda Finesse

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Evenflo Advanced Double Electric

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Maine Community Health Options - Options

Please select only one.

Medela Pump In Style with MaxFlow

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Medela Freestyle

Medela Freestyle Double Electric

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Lansinoh Smartpump 2.0 Double Electric

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Spectra S1 Plus

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Spectra S2 Plus

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Spectra S9

Spectra 9 Plus

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Viverity True Ease Single

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Ameda Finesse

Ameda Finesse

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Evenflo Advanced Double Electric

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Harvard Pilgrim Options

Please select only one.

Lansinoh Signature Pro

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Medela Freestyle

Medela Freestyle Double Electric

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Spectra S9

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Viverity True Ease Single

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Ameda Finesse

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Aetna Options

Please select only one.

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Lansinoh Signature Pro

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Medela Freestyle

Medela Freestyle Double Electric

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Spectra S1

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Spectra S9

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Viverity True Ease Single

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Ameda Finesse

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Qualcare Options

Please select only one.

Lansinoh Signature Pro

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Medela Freestyle

Medela Freestyle Double Electric

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Spectra S9

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Viverity True Ease Single

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Ameda Finesse

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Evenflo Advanced Double Electric

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Martin's Point US Family Health Plan - Options

Please select only one.

Medela Pump In Style with MaxFlow

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Medela Freestyle

Medela Freestyle Double Electric

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Lansinoh Smartpump 2.0 Double Electric

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Spectra S1 Plus 

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Spectra S2 Plus 

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Spectra S9

Spectra 9 Plus

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Viverity True Ease Single

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Ameda Finesse

Ameda Finesse

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Evenflo Advanced Double Electric

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

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Spectra Pump Specific Addons {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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YesNo NoYes
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Our Privacy Policy and HIPPA Policy

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Check out with PayPal
Processing PayPal Payment
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Insurance Breast Pump Form

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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.

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Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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I acknowledge that I have not received a breast pump through Mainecare for this year. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Baby Due Date or Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Model Interested in? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Lansinoh Smartpump 2.0 Double Electric {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Signature Pro

Lansinoh Signature Pro {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S2 Plus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

Spectra 9 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Viverity Tru Comfort Deluxe Double Electric

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

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

Ameda Finesse {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Evenflo Advanced Double Electric {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Anthem Blue Cross and Blue Shield - Options

Lansinoh Signature Pro

Lansinoh Signature Pro {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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$20 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medela Pump In Style with MaxFlow

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

Medela Freestyle Double Electric

$230 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Smartpump 2.0 Double Electric

$20 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S1 Plus

 

$150 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S2 Plus

 

$60 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

Spectra 9 Plus

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

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

Ameda Finesse

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

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

Medela Pump In Style with MaxFlow

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

Medela Freestyle Double Electric

$250.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Smartpump 2.0 Double Electric

$40 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S1 Plus

$175 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S2 Plus

$95 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

Spectra 9 Plus

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

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

Ameda Finesse

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

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

Lansinoh Signature Pro

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

Medela Freestyle Double Electric

$105.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Smartpump 2.0 Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S1 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S2 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

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

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

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

Spectra S2 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Medela Pump In Style with MaxFlow - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Signature Pro

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

Medela Freestyle Double Electric

$195.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Smartpump 2.0 Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S1

$75.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

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

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

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

Lansinoh Signature Pro

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

Medela Freestyle Double Electric

$95.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Lansinoh Smartpump 2.0 Double Electric - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S1 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S2 Plus - $0.00 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

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

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

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

$30.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Martin's Point US Family Health Plan - Options

Medela Pump In Style with MaxFlow

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

Medela Freestyle Double Electric

$160.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Lansinoh Smartpump 2.0 Double Electric

$65.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S1 Plus 

$100.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S2 Plus 

$55.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Spectra S9

Spectra 9 Plus

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

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

Ameda Finesse

$45.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Evenflo Advanced Double Electric

$70.00 Upgrade {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Your Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Your Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Height {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Weight (Not Required) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Can we email you about your order? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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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 }
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Please Upload Prescription {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Physician Information

Physician Name* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Prescribing Physician Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Physician Practice Name* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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City of Physician Practice* {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
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Emergency Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Newsletter Signup? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
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Who referred you to us? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Name (We'd like to thank them!) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Preferred Method of Contact? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Insurance Group # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Payer ID # {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
OR Upload Picture of Insurance Card (Not Required) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ Cognito.resources['fileupload-dropzone-message'] }}
{binding Name, mode=oneTime}
{binding Description}

{ binding firstError.message }
Recommended Addons to give you the best pumping experience.  {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Spectra Pump Specific Addons {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
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}
{ binding firstError.message }
I have viewed Bedard Medical Supplies Privacy and HIPPA Policy {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Our Privacy Policy and HIPPA Policy

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