BREMO BREAST PUMP ELIGIBILITY FORM

Please note: This form is HIPAA compliant, and all your information will be kept private and confidential. A prescription is required for breast pumps through insurance.

TELL US ABOUT YOURSELF


Due date/ Delivery date*:


PRIMARY INSURANCE INFORMATION

Please complete this form and call 804-285-7730 to speak with a staff member about a breast pump.


Thank you for choosing Bremo pharmacy as your breast pump provider.

Note: If you will be renting a pump:

- Call Bremo Pharmacy at 804-288-8361 to speak with a staff member
- The breast pump will need to be picked up from Bremo Pharmacies Office & Training Center by appointment.
- 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? *


Requirements for a pump through insurance:

-Please note, we may require proof of medical necessity from your physician 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 48 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 48 business hours (Monday – Friday) with more information.

We also have other blog articles for expecting mothers regarding medications and other needs that you may find full of helpful tips.