Nursing Nook - Breast Pump Request Form (Please Read Carefully)

Congratulations on your new addition! Thank you for choosing Nursing Nook LLC for your breast pump order. To ensure timely processing, please fill out this form completely, select ONE (1) breast pump, and sign at the bottom. If you have questions, call us at 406-721-5440 and leave a message—we'll call you back.

We can submit claims to most Aetna plans, Allegiance, BCBS of MT* (see details below), Cigna, EBMS, First Choice Health, Missoula County, Mountain Health CO-OP, and Pacific Source. Click your insurance provider's name to see coverage. ALL INSURANCE CLAIMS MUST BE RUN THROUGH YOUR PRIMARY INSURANCE PROVIDER. If you submit a claim under an insurance provider that is not your primary, and we are not in network with your primary provider, you will be held responsible for the dollar amount of your pump, paid in a timely manner. If you don't know who your primary provider is, please give one of your insurance companies a call before submitting this form.

Most insurance plans will cover 1 pump per calendar year, but there are some plans that cover 1 per every live birth, or one per 3 years. If you have utilized your breast pump benefit per your insurance plan, you are no longer eligible for another breast pump.

BCBS Plans:

  • We CAN submit claims if you have BCBS of Montana, or you live in Montana with BCBS of another state. 
  • We CANNOT submit claims if you live out-of-state with out-of-state BCBS, or if you have Federal Blue Cross.

If you no longer need a pump, email us at nursingnookllc@gmail.com or call 406-721-5440 to cancel.

By signing this form, you authorize Nursing Nook LLC to verify your insurance benefits and submit a claim. If insurance does not cover 100%, we’ll contact you before proceeding to tell you of any out of pocket amount there may be. 

Important: We cannot submit claims for HMO plans, Medicaid, Federal BCBS, Cox, or First Health plans. Contact your insurer for more details.

Claims may take 10-14 business days to be billed. Order processing time is 7-10 business days and then standard shipping time. If you need a pump sooner, want expedited shipping (at your expense) or have questions, please call or email us. 

(406) 721-5440 or NursingNookllc@gmail.com

Orders are not set in stone until the pump is in the mail on its way to you, if you need to change your pump choice or have any questions, you're welcome to call or email at the information above, we want you to have the pump you want to have, so if there is a pump you are interested in that you don't see on the list below, please let me know and we are happy to try our best to receive the pump for you! 

Coverage and timelines are estimates and may vary by plan.

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I have read and agree to the terms written above, by checking this box, I verify that I will fill out this form to the best of my knowledge with correct information, I verify that I have provided my PRIMARY insurance information to be billed, I understand that processing times can be 7-10 business days, and if I decide I will place an order elsewhere, I will be sure to contact the Nursing Nook to cancel my order. *
Required
Last Name *
First Name *
Phone Number *
Street Name and Number *
City, State and Zip *
Email *
Date of Birth *
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Due Date *
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Preferred contact method *
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IMPORTANT! PLEASE READ, NOT READING MAY COST YOU UP TO $500!! Please only provide us with the information for your PRIMARY insurance carrier, if you are covered under multiple insurance providers, only your primary will cover your breast pump! Your secondary will not cover your breast pump under any circumstances. If you are multi-insured and do not know your primary insurance provider, please give your insurance providers a call before submitting your request!
PRIMARY Insurance Provider *
Member ID # *
Group # *
Primary Insured *
Primary Last Name
Primary First Name
Primary Date of Birth
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Primary Address (include City, State, Zip)
Would you like us to contact you *
Please only choose ONE (1) breast pump. Your insurance will cover 100% of their allowed, maximum benefit, which is dependent by company and/or plan. This does not mean they will cover 100% of any breast pump you'd like. Each insurance reimbursement is different, we carry basic breast pump models to ensure there is always at least one option fully covered. If you would like a model not fully covered by insurance, you may upgrade to the model of preference and pay the difference for what insurance will not cover. Please call if you have any further questions regarding benefit or upgrade information 406-721-5440.
Please only choose ONE (1) breast pump. *
HIGHLY RECOMMENDED!! (skip if not interested) Flange Size (you can approximately measure with a coin or visit this link (preferred method) to print a printable flange ruler, best time to size is in the late third trimester. Please round up 1-2 mm to the next closest size or select the last option if you need more assistance!
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PATIENT’S OR AUTHORIZED PERSON’S RELEASE OF MEDICAL INFORMATION & PAYMENT INFORMATION (Please Read and Sign Below)
1) I authorize the release of any medical or other information necessary to process this insurance claim into the online insurance clearinghouse or FAX or MAIL to my insurance carrier. I also request payment of government benefits either to myself or to the party who accepts assignment.
2) I authorize payment of medical benefits to the Nursing Nook LLC for services described in the health insurance claim form. I understand that in the event my insurance does not cover the billed services I am responsible for paying the billed charges.
3) I agree that if this account is not paid when due, and Nursing Nook LLC should retain an attorney or collection agency for collection, I agree to pay all costs of collection including reasonable interest, reasonable attorney’s fees (whether or not a lawsuit is filed) and reasonable collection agency fees in the amount of 50% of the balance due.

Electronic Signature *
Today's Date *
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For Office Use: Pump Serial #____________________________________________
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