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Get Neb Medical Order Form

Phone 708 633 1560 Fax 708 633 1574 Email maternity nebmedical.com N.M. S. Use Only 4. 1 Pat. Clinic NPI 1053364695 Tax ID 201668371 Sales ID th 7646 W. 159 Street Orland Park IL 60462 Breast Pump Rx and Order Form Breast pumps are covered by most insurances per the Affordable Care Act. We will verify each patient s insurance coverage if requested Date Patient Information equipment will be billed under mother Delivery / Shipping Information Mother s First Name MI Ship to if different Mother s Last Name Shipping Address DOB // Unit / Apt Phone City State Zip Insurance Information Please attach a copy of insurance card All HMO s require prior authorization FHN and all HMO s need pre-authorization by insurance. Please send pre-auth to insurance and include a copy to Neb Medical Services Policy Holder s First Name Last Name DOB // if different from Mother s name Pri. Phone 708 633 1560 Fax 708 633 1574 Email maternity nebmedical*com N*M. S* Use Only 4. 1 Pat. Clinic NPI 1053364695 Tax ID 201668371 Sales ID th 7646 W* 159 Street Orland Park IL 60462 Breast Pump Rx and Order Form Breast pumps are covered by most insurances per the Affordable Care Act. We will verify each patient s insurance coverage if requested Date Patient Information equipment will be billed under mother Delivery / Shipping Information Mother s First Name MI Ship to if different Mother s Last Name Shipping Address DOB // Unit / Apt Phone City State Zip Insurance Information Please attach a copy of insurance card All HMO s require prior authorization FHN and all HMO s need pre-authorization by insurance. Please send pre-auth to insurance and include a copy to Neb Medical Services Policy Holder s First Name Last Name DOB // if different from Mother s name Pri. Ins* NamePolicy Group Pri Ins* Referral/Auth Secondary Name Policy Group Clinic Information Please print physician name and include NPI for providers new to NMS Physician First Name Last NPI Clinic Name Address Suite Phone Certificate of Medical Necessity This form also functions as a Prescription for an electric breast pump QTY 1 Breast Pump Double Electric E0603 QTY 2 Breast Shield A4284 QTY 2 Disposable Canister A7000 Equipment Prescribed HCPCS QTY 2 Tubing used with pump A7002 Length of need 99 months purchase Serial Number NMS use only Dx Other Postpartum lactating mother V24. 1 Physician Signature Stamps not acceptable Confidential Information Fax to Neb Medical Services with copy of insurance card and HMO pre-authorization at 708 633 1574. Phone 708 633 1560 Fax 708 633 1574 Email maternity nebmedical*com N*M. S* Use Only 4. 1 Pat. Clinic NPI 1053364695 Tax ID 201668371 Sales ID th 7646 W* 159 Street Orland Park IL 60462 Breast Pump Rx and Order Form Breast pumps are covered by most insurances per the Affordable Care Act. We will verify each patient s insurance coverage if requested Date Patient Information equipment will be billed under mother Delivery / Shipping Information Mother s First Name MI Ship to if different Mother s Last Name Shipping Address DOB // Unit / Apt Phone City State Zip Insurance Information Please attach a copy of insurance card All HMO s require prior authorization FHN and all HMO s need pre-authorization by insurance.

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