Get Btricareb Breast Pump Order Form Contract - Tidewater Lactation Group

Completing the BTricareb Breast Pump Order Form Contract is an essential step in obtaining a breast pump through Tidewater Lactation Group. This guide provides clear, step-by-step instructions to help users complete the form online effectively.

Follow the steps to successfully complete the order form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin filling out the Patient Information section. Ensure that all fields are completed accurately, specifically entering the Name (Mother), Mother's Date of Birth, Street Address, City/State/Zip, and Phone number.
3. Provide the Baby's Date of Birth or Due Date. This information is critical for the prescription processing.
4. Complete the Sponsor's Name and their FULL Social Security Number. This ensures proper identification and verification.
5. Indicate the relationship to the Sponsor. This information helps in understanding the connection between the parties involved.
6. Fill in the Email Address for communication purposes. Ensure it is an active account that you check regularly.
7. Select your desired breast pump from the provided options. Each selection includes specific features, so ensure you choose one that meets your needs.
8. Read and acknowledge the statement regarding the authorization to submit claims to Tricare and the handling of nonpublic personal information by signing and dating in the designated area.
9. Once all sections are accurately filled, save your changes to preserve the information.
10. You can then download or print the completed form for your records, or share it via email or fax to Tidewater Lactation Group using the provided contact details.

Get started today and complete your BTricareb Breast Pump Order Form online to ensure timely assistance.