Order Milk Bags

1Your Insurance Information

2Your Information

3Billing and Signature

All orders will come in 1 month supply (100 milk bags)

All orders will come in 1 month supply (120 milk bags)

All orders will come in a 2 month supply (2) 100ct milk bags

All orders will come in a 3 month supply (3) 100ct milk bags

All orders will come in 3 month supply (360 milk bags)

Milk Bags

Price:

Where Do You Live?(Required)

Your Provider(Required)

Your benefit is available on the anniversary date of your insurance plan and may not be available at the time of this order or when your breast pump ships. We will be able to process your milk bag order after the anniversary date of your plan which will be listed on the eligibility verification that we obtain through Blue Cross.

Your Information

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Date of Birth(Required)

Due Date(Required)

Shipping Address(Required)

Street Address City State ZIP Code

OBGYN / Midwife Name

First Last

OBGYN / Midwife Phone Number

How did you hear about us?

Referral Details

Please provide the name of the hospital, insurance, manufacturer, etc. that referred you to this site.

Insurance Information

Member ID

Group Number

If you do not have a group number please enter 0000

Prescription Upload(Required)

Drop files here or

Accepted file types: jpeg, jpg, png, pdf, gif, Max. file size: 4 MB, Max. files: 1.

A prescription is required in order to place your order. Here is a template if you do not already have one that can be filled out by your physician. Please return to this ordering form and upload the prescription once you have received it.

Insurance Card Upload(Required)

Drop files here or

Accepted file types: jpeg, jpg, png, pdf, gif, Max. file size: 4 MB, Max. files: 2.

Blue Cross Acknowledgement(Required)

If we identify your Blue Cross plan is classified as a self-insured payer you will be required to sign an additional form identifying your responsibility in the event your employer group does not cover the expected benefit.

Aetna Acknowledgement(Required)

If we identify your Aetna plan is classified as a self-insured payer you will be required to sign an additional form identifying your responsibility in the event your employer group does not cover the expected benefit.

United Acknowledgement(Required)

If we identify your United plan is classified as a self-insured payer you will be required to sign an additional form identifying your responsibility in the event your employer group does not cover the expected benefit.

Acknowledgement(Required)

I understand that I’m entitled to a 3 month supply of milk storage bags under my insurance benefit. I authorize Breastpumps.com to verify my insurance coverage and provide me with the milk storage bag supply allotted by my insurance plan.

Acknowledgement(Required)

I understand that I’m entitled to a 2 month supply of milk storage bags under my insurance benefit. I authorize Breastpumps.com to verify my insurance coverage and provide me with the milk storage bag supply allotted by my insurance plan.

Acknowledgement(Required)

I understand that I’m entitled to a 1 month supply of milk storage bags under my insurance benefit. I authorize Breastpumps.com to verify my insurance coverage and provide me with the milk storage bag supply allotted by my insurance plan.

California Member Reimbursement Acknowledgement(Required)

You will be charged $118.80 for your milk bag order. The $118.80 accounts for the expected reimbursement which will be paid directly to you as the member and not us as the provider. We will submit your insurance claim but payment for the claim will be directed to you as the plan member and not our organization.

Billing and Signature

Tax

$0.00

Your Total

Billing Address(Required)

Same as shipping

Billing Details(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Form Submitter Signature(Required)

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Tracking Number

This field is hidden when viewing the form

Order Status

Does Your Insurance Qualify?

Need help? Give us a call at 888-495-7491 Monday - Friday, 8:30 a.m. - 5:30 p.m. and Saturday/Sunday 9:00 a.m. -- 5 p.m.

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Order Milk Bags

Your Information

Insurance Information

Billing and Signature

Does Your Insurance Qualify?