Resupply Request Form

Fill out our Resupply Request Form to see if you are eligible for milk storage bags and/or breast pump replacement parts through your insurance. This program provides these items at no cost to you!

Need to order a breast pump? Fill out our Fast Track From

Once you fill out this form, we will contact you to provide you updates on your request. This is a new program that we are working on expanding; not all insurances are currently eligible for the program. We will not send you anything that is not covered by your insurance.

Name
This field is for validation purposes and should be left unchanged.
Have you worked with Milk Moms before?(Required)
How were you referred to Milk Moms?(Required)
Please Describe "Other"(Required)
Order Information
Which resupply program are you interested in?(Required)
Choose your breast pump resupply kit(Required)
If you do not see your size below, it means we do not currently carry it. We are working to expand our offerings and include additional sizes.
Medical Necessity(Required)
I confirm that I am still using my breast pump and that I need replacement parts.(Required)
Do you have a copy of your prescription for these items?(Required)
Prescription
Please upload your prescription below or send it to us. Fax: 763-413-9741 | Text: 763-259-8824 | Email: [email protected].
Max. file size: 50 MB.
Provider Name(Required)
Please enter the name of your OB provider/midwife (whoever would be signing the prescription).
Provider Facility(Required)
Please enter the name of the clinic/hospital/midwifery/etc. that your provider works at.
Provider Facility City(Required)
Please enter the name of the city your provider is located.
Provider Phone #(Required)
Please enter the contact number for your provider/facility.
RX Consent(Required)
I give Milk Moms permission to reach out to my provider on my behalf to obtain a prescription.(Required)
Demographic Information
Name(Required)
First Last
Date of Birth(Required)
MM slash DD slash YYYY
Address(Required)
Street Address Address Line 2 City State ZIP Code
Phone(Required)
Email(Required)
Insurance Information
Insurance Company(Required)
Insurance ID #(Required)
Insurance Group #
What is your relation to the policy holder?(Required)
Please describe the relation(Required)
Policy Holder's Name(Required)
First Last
Policy Holder's Date of Birth
MM slash DD slash YYYY
Do you have any other insurance?(Required)
Secondary Insurance Company(Required)
Secondary Insurance ID #(Required)
Consent
Consent(Required)
By checking this box I consent to Milk Moms contacting me via phone, text, and email, and I consent to the Privacy Policy(Required)
Assignment of Benefits(Required)
This AOB form is required to bill on your behalf. 1. Assignment of Medicare, Medicaid, Medicare Supplemental or other insurance benefits to Milk Moms, Inc for medical supplies furnished to me by Milk Moms, Inc. 2. Direct billing to Medicare, Medicaid, Medicare Supplemental or other insurance(s). 3. Release of my medical information to Medicare, Medicaid, Medicare Supplemental or other insurance and their agents and assigns. 4. Milk Moms, Inc to obtain medical or other information necessary in order to process my claim(s), including determining eligibility and seeking reimbursement for medical supplies and/or medication(s) provided. 5. Milk Moms, Inc to contact me by telephone or mail regarding my medical supplies and/or medication(s) order. I agree to pay all amounts that are not covered by my insurance including applicable co-payments and/or deductibles for which I am responsible. I request that payment of Medicare, Medicare, Medicaid, Medicare Supplemental or other insurance benefits be made on my behalf to Milk Moms, Inc for any medical supplies and/or medications furnished to me by Milk Moms, Inc. I authorize any holder of medical information about me to release to Milk Moms, Inc, my physician(s), caregiver, CMS, its agents and to my primary and/or other medical insurance any information needed to determine or secure eligibility information and/or reimbursement for covered services. I agree to pay all amounts that are not covered by my insurance(s) and for which I am responsible. I agree to pay all amounts that are not covered by my insurance including applicable co-payments and/or deductibles for which I am responsible. Deductible amount to be patient’s responsibility of up to $2.65 for Minnesota Medicaid recipients. I understand and agree that if I am choosing to upgrade the 'basic/standard' model covered by insurance to a more expensive model, that I am responsible for the additional charges and that it is not a provider write off but a product upgrade charge and agree to pay the additional cost.
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, Warranty/Payments/Returns, and Assignment of Benefits.
Electronic Signature(Required)

Resupply Request Form

Order Information

Demographic Information

Insurance Information

Consent

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