HealthEZ Breast Pump Order Form

Breast pump ordering made easy.

Milk Moms has partnered with HealthEZ to provide HealthEZ members with a quick and easy way to obtain a breast pump for free (you can view the HealthEZ breast pumps here). You have most likely already spoken with your HealthEZ insurance and were directed here. Please fill out this form to order your breast pump. Once you fill out this form we will:

· Contact you within 1 business day (if you choose to be contacted)

· Verify your insurance eligiblity

· Ship your pump, free of charge, direct to you!

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This field is for validation purposes and should be left unchanged.
Have you worked with Milk Moms before?*
Demographic Information
Name (as it appears on your insurance card)*
First Last
Date of Birth*
MM slash DD slash YYYY
Baby's DoB/Due Date*
MM slash DD slash YYYY
Address*
Please do not put a PO Box. We are unable to ship to PO Boxes

Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Insurance Information
Insurance Company*
Insurance ID#*
Do you have any other insurance?*
Order Details
Choose your pump*
All of these pumps are fully covered through HealthEZ at no additional cost to you. Get more info on these pumps at HealthEZ Breast Pumps
Would you like to be contacted about your order?*
If you say "no", your order will be processed without contacting you. You will still receive a tracking notification when your order is shipped. Even if you say "no", we may need to contact you if there are any issues or questions regarding your order.
How were you referred to Milk Moms?*
Notes/Comments
Consent*
By checking this box I consent to Milk Moms contacting me via phone, text, and email. Privacy Policy*
Consent*
By checking this box I confirm that I have read and agree to the terms and information in the Consent and Authorization Form, including the HIPAA Privacy Notice, Patient Rights and Responsibilities, Service Availability, Plan of Care, Product Training, Medicare Supplier Standards, Suggestions and Complaints, and Warranty/Payments/Returns.*
Electronic Signature*
Please type your name below to confirm all details on this form.

HealthEZ Breast Pump Order Form

Demographic Information

Insurance Information

Order Details

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