PUMPCARE QUALIFICATION FORM

Complete our Quick Qualification Form

Let's Get Started...

Customer Information

Date Of Birth

Primary Insurance Information

Attach a photo of your Insurance or Medicaid Card

Secondary Insurance Coverage.

Attach a photo of your Insurance or Medicaid Card

Tell Us More About Yourself

Have You Been Diagnosed With breastfeeding? YESNO

Do You Currently Have A BREAST PUMP? YESNO

I Authorize PediaCare To Contact Me By Phone, Email Or Text. PediaCare Will Not Share Or Distribute This Information. By Checking This Box, I Confirm That I Have Not Received BREAST PUMPS From Another Provider In The Last Three Months.

Get A Breast Pump In 3 Simple Steps

Complete PediaCare’s Quick Qualification Form.

Your dedicated PedicaCare Medical Specialist contacts your insurance provider and doctor to verify coverage and submits required paperwork.

PedicaCare Med will set you up with the best Breast Pump to fit your specific needs. We will also remind you when it’s time to reorder your Breast Pump supplies so you’ll never forget.

Congrats! Your Breast Pump and supplies will be shipped straight to your front door!

Auto-Ship

We will automatically ship fresh supplies to you on a schedule recommended by most Nebulizer experts, manufacturers and insurance companies.

Courtesy Contact

We will call or email you when you are eligible to see if you are ready to Refresh your supplies.

Resupply

Once you sign up with a DME to receive equipment through insurance such as a PAP machine, breast pump, or incontinence supplies, you may notice an option to join a resupply program.