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Breast Pump Order Form

Woman holding hands with an infant

Nationwide Breast Pump Ordering

The hassle-free way to get a breast pump through insurance.


Order Today

 

Welcome, and congratulations!

Whether you are a first-time mom or a seasoned professional, we are happy to help you along your journey!

Below you will see an order form to receive a breast pump through your insurance. To get things started, please fill out as much of the form as possible. If you have a prescription from your doctor, please snap a picture and upload it with your submission. This will ensure we can get to work on your order right away.

 

 

Here's How It Works 

 

Step 1

Fill out our online form below.

Step 2

We verify your insurance and prescription.

Step 3

We'll send it to you - FREE.

 

 

 

Breast Pump FAQ's
How much will I have to pay for my breast pump?

How long will it take to get my breast pump?
What breast pumps can I choose from?
Are there any breast pump accessories I should know about?
Will I own the breast pump or will this be a rental?

 

 

 

Order Yours Today!

  • Breast Pump Order Form

  • * - Indicates a required field

  • This can be found on an Invoice or Pick Ticket

  • By checking this box you approve Binson's Medical Equipment & Supplies to use a valid credit card to collect copay and or deductible amounts associated with your order. If you do not have a valid Credit Card on file, or if we require additional information to complete your order, a Binson's representative will contact you.

  • Insurance Information

  • Physician Information

  • Upload an RX

  • Don't have an RX? Send this form to your doctor.

  • Billed charges could be applied to yearly deductibles and/or copays. Binson's will attempt to collect the required documentation and bill the insurance claim. No returns on insurance sales, all other returns in 30 days (restocking fee may apply).

  • Assignment of Benefits (AOB):

  • I acknowledge receipt and understanding of Binson's notice of health information privacy practices which provides a description of how Binson's may use and disclose my health information, patient rights & responsibilities, CMS standards, and important information notification. I give consent to Binson's to use and disclose this information for the purposes of: Treatment, payment of authorized benefits on my behalf, health care operations, obtaining information from any health care provider for proper determination of benefits payable, and releasing to my insurance company necessary information for reimbursement for any product/service provided to me. I request payment of authorized Medicare or other payor benefits be made on my behalf to Binson's for any services rendered by Binson's . I agree and understand that I am responsible for any charges not covered by my insurance. I will notify Binson's of any changes in my insurance coverage.

  • NOTICE OF COMMUNICATION PRACTICES AND RELEASE REGARDING COMMUNICATIONS:

  • By signing this form below, I give Binson's or its authorized vendors or agents, permission to contact me or persons acting on my behalf by telephone, pre-recorded calls, text messages, calls generated by an automated telephone system or by fax, at any telephone number, including any wireless or cell phone number, that I or any healthcare provider making a referral for me to Binson's provided to Binson's. Contacts may include but are not limited to equipment, supplies, re-orders or renewal supplies, upgrades, optional equipment, or any information concerning treatment, payment or operations. I understand that I am not required to provide this consent to Binson's in order to purchase goods or services from Binson's. Please contact Customer Service at 888.246.7667 to limit customer contact.

  • Disclosures
  • Provide your signature below

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Orders submitted online will be delivered to the patient by mail within 10 business days after shipping from our facility. If you have questions regarding your order, email us at contact@binsons.com.

Thank you for choosing Binson's! We look forward to serving you.

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