Get Neb Medical Order Form

Completing the Neb Medical Order Form online is a straightforward process that ensures you provide all necessary information for obtaining a breast pump covered by your insurance. This guide will walk you through the sections and fields of the form to help you fill it out accurately and efficiently.

Follow the steps to complete the Neb Medical Order Form online

1. Press the ‘Get Form’ button to access the Neb Medical Order Form and open it in your preferred online editor.
2. Begin by entering the date at the top of the form, which indicates when you are submitting the request.
3. In the patient information section, input the mother’s first name, middle initial (if applicable), last name, and date of birth.
4. Provide the shipping address for the breast pump, including unit/apt number, phone number, city, state, and zip code.
5. Fill out the insurance information by attaching a copy of the insurance card. Include the policy holder’s name (if different from the mother), date of birth, primary insurance name, policy number, and group number.
6. If applicable, provide secondary insurance details in the same format as the primary insurance.
7. In the clinic information section, print the physician's first and last name, NPI number, clinic name, address, and phone number.
8. For the certificate of medical necessity, note the quantity of equipment prescribed (e.g., breast pump, breast shield, tubing, etc.). Include the diagnosis if it is known.
9. Ensure the physician's signature is included as stamps are not acceptable. Also, enter the date of signing.
10. Finally, fax the completed form to Neb Medical Services at (708) 633 – 1574 along with the copy of the insurance card and any required pre-authorization documents.

Complete your Neb Medical Order Form online today to ensure you have the necessary equipment for your lactation journey.