PART I - COMPLETE PATIENT DEMOGRAPHICS

 

PART II - SELECT BREAST PUMP MODEL

The Patient is responsible for any co-payments and deductibles that may be applied by your insurance plan. Our Customer Service Associate will advise you as to which Breast Pump your Plans benefit covers. If you wish a Breast Pump with more features, your Insurance Plan's reimbursement amount can be applied toward the purchase of the upgrade.

    • Ameda Purely Your Personal Double Electric Breast Pump

      This unit is a Dual Hygiene Milk Collection System and comes with 2 bottles, 2 Breast Flanges, tubing and DVD.

    • Ameda Purely Yours Ultra

      Comes with all the features found in the Ameda Purely Yours with Tote but a Large pebbled faux leather bag

    • Medela PNS Starter Double Electric Breast Pump

      This pump comes in a carry case which includes 2 bottles, 2 shields, tubing, and a power pack.

    • Medela Pump In Style Tote

      Comes with a large, all-in-one carry case, 4 bottles, Cooler Bag, (2) 24mm shields, Flanges, Battery Pak.

    • Medela Freestyle Breast Pump

      Pump in style advanced tote, but with a backpack for storage.

    • Medela Freestyle Breast Pump

      Compact unit (weighs less than 1 pound) for hands-free operation. Comes with Bottles, Cooler Set, Rechargeable Battery and attractive Tote Bag.

    • Megna M7 Mini Breast Pump

      Compact, powerful, and FDA approved. Portable for the on the go mom.

    • Spectra S2

      Lightweight, powerful and quiet.

    • Spectra S2

      Lightweight, powerful and quiet. Comes with internal, rechargeable battery.

    • Spectra S2

      Comes with a black carry bag, and a pink cooler.

    • Spectra S2

      Compact, powerful, portable, quiet.

    • Medela Easy Expression Bustier (Retail Item)

      Gives you the freedom to do other things while pumping. Goes perfectly with the Medela Freestyle Breast Pump,

    • Medela Accessory Starter Kit (Retail Item)

      30 Disposal Nursing Bra Pads, 2oz. Tube of Lanolin. For Tender Breast, 20 Breast Milk Storage Bags, 20 Accessory Wipes, 5 Micro-Steam Bags.

    • Medela Battery Pak (Retail Item)

      Exclusively for use with Pump In Style Original and Traveler models. Uses 8 AA alkaline or rechargeable batteries* (* NOT INCLUDED) for approximately 3 hours of pumping. Black microfiber carrying case fits inside Breast Pump bag or can easily be attached to bag strap.

    • Medela 9-volt Vehicle Adapter (Retail Item)

      Compatible with the Pump In Style Breastpumps built after 2007

    • Medela Cooler Set (Retail Item)

      The Breast Milk Cooler Set is great as an extra set for bringing to work or school to store pumped Breast Milk or for leaving at daycare with your baby.

    • Medela Shoulder Bag with Cooler Set (Retail Item)

      Each set comes with a complete Pump In Style Advanced double pumping kit* and a spare cooler with a contoured ice pack.

    • Medela Messenger Bag with Cooler Set (Retail Item)

      Each set comes with a complete Pump In Style Advanced double pumping kit* and a spare cooler with a contoured ice pack.

    • Medela 5 oz Bottles (6 Pack) (Retail Item)

  • PLEASE FAX THE PRESCRIPTION (IN THE MOTHER'S NAME) FROM YOUR PHYSICIAN, TO 888-323-5249 OR EMAIL TO breastpump@bairdrespiratory.com.


PART III - GET RX FROM YOUR PHYSICIAN

ASSIGNMENT OF INSURANCE BENEFITS AND RELEASE OF INFORMATION:I hereby authorize my public and/or private insurance company or funding resource responsible for paying for my care, if applicable, to pay benefits on my behalf directly Baird Respiratory & Medical Equipment, for any products and services furnished to me by Baird Respiratory & Medical Equipment, I also authorize Baird Respiratory & Medical Equipment, to request, on my behalf, all public and private insurance benefits for products and services provided to me by Baird Respiratory & Medical Equipment I hereby authorize Baird Respiratory & Medical Equipment to release my medical records to any person, organization, company and/or agency which is or may be (1) involved in providing care for me or (2) liable for any portion of the payment of the charges for such products and services.