BREMO BREAST PUMP ELIGIBILITY FORM
Please note: This form is HIPAA compliant, and all your information will
be kept private and confidential.
TELL US ABOUT YOURSELF
Due date/ Delivery date*:
PRIMARY INSURANCE INFORMATION
Thank you for choosing Bremo pharmacy as your breast pump provider.
Note: If you will be renting a pump:
- The breast pump will need to be picked up from Bremo pharmacy @ Henrico
- A rental agreement will need to be filled out upon pickup.
- Also, a credit card must be placed on file as a part of the rental agreement.
Some plans may require specific documentation from your prescriber.
* Please call 804-285-7730 if you have any questions.
Insurance card information:
Have you received a breast pump through insurance during this pregnancy?
If you have, please select yes. Knowing this, will allow us to ask your
insurance the correct questions and prevent you from any potential financial
Requirements for a pump through insurance:
- Please note, we may require proof of medical necessity from your physician
(such as having twins, currently having a baby in the NICU), if applicable.
OB/GYN or SPECIALTY PHYSICIAN INFORMATION
Please scan and attach your prescription and insurance card (front and
You may fax a copy to us at (804) 285-8769. You may also bring in the
insurance card/ prescription at pick-up (unless a Prior Authorization is
- Once you fill out the form, you will receive a follow-up phone call
from us within 24 business hours (Monday through Friday).
- The insurance only provides eligibility information and it is not a
guarantee of payment and you may be subject to any deductible/ copay that
is owed as part of your insurance plan.
Thank you for submitting your form to Bremo Pharmacy!
We will contact you within 24 business hours (Monday – Friday) with
** Also, don’t forget to print off your 10% off coupon (for supplies)
found at the end of the blog! **
We also have other blog articles for expecting mothers regarding medications
and other needs that you may find full of helpful tips.