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 Doctors’ Hospital.
- 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 liability.


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



Document upload:

Please scan and attach your prescription and insurance card (front and back) here:
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 needed).

 

 

Please note:

- 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 more information.

Please visit our blog post on Breast Pumps and Important Supplies at https://bremorx.com/breastpump-supplies/HTML to learn more about additional products that will make use of your pump convenient and hassle-free.

** 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.