Service Request Form

This field is for validation purposes and should be left unchanged.

Order Details

Service Requested*

Maternity Items Requested

Please select the maternity items you are requesting.

Compression Socks
Pregnancy Support Band
Postpartum Recovery Garment

Insurance Plan

Our Car Seat Program is only available for select insurances. If you do not see your insurance plan listed, then you would not currently be eligible for our program.

Insurance Plan

If you do not see your insurance listed, please select “My Insurance Is Not Listed”.

Please Enter Your Insurance Plan

If your insurance is not listed above, it does not mean we do not work with them. Please provide us with the name of your insurance.

Have you worked with Milk Moms before?*

Have you received a breast pump?*

Are you interested in receiving a breast pump?*

How were you referred to Milk Moms?*

Demographic Information

Name (as it appears on your insurance card)*

First Last

Date of Birth*

Baby's DoB/Due Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Insurance Information

Insurance ID#*

Insurance Group #*

Do you have any other insurance?*

Consent

Consent*

By checking this box I consent to Milk Moms contacting me via phone, text, and email. Privacy Policy*

Assignment of Benefits*

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*