Bili Blanket Baby

*Providers please do not use this form. This is for the family to fill out. Please see How to Order above for more info.*

1. Choose your insurance provider

Do you have coverage through one of the following providers?

Insurance:

Please choose the option that represents your baby’s medical insurance coverage, understanding your baby is likely not yet enrolled.

Colorado Medicaid

TRICARE West

All Others

(Commercial insurance through employers, private pay, etc.)

Language:

English

Español

Temporary Authorization/Hold $395.00

Temporary Authorization/Hold Requirement: To qualify to rent a biliblanket, the renter must present a valid major credit card or debit card with available credit. At the time of rental, an authorization hold of $395.00 will be secured on the credit/debit card provided, to cover the estimated rental charges that may be incurred. These funds will not be available for your use. Your final billing details will be determined after the equipment is returned.

Autorización temporaria/Requisito de retención $395.00

Autorización temporaria/Requisito de retención: Para calificar al alquiler de un biliblanket, quien alquila debe presentar una tarjeta de crédito o débito válida con saldo disponible. Al momento del alquiler, se asegurará una retención de autorización de $395,00 en la tarjeta de crédito o débito proporcionada para cubrir los costos estimados del alquiler en los que se pueda incurrir. Estos fondos no estarán disponibles para su uso.

TRICARE BREAST PUMP BENEFIT

Check this if you would like an electric breast pump delivered to your house. (There is no out of pocket cost for one electric breast pump per pregnancy.)

Damage Waiver - $35.00 to be charged at final billing (optional)

You have the option to purchase a damage waiver for a one time upfront fee of $35.00 which covers unintentional damage to the Equipment during the Rental Period. Please see your completed Equipment Lease Agreement and Disclosures Document for additional details.

COLORADO MEDICAID BREAST PUMP BENEFIT

Check this if you would like an electric breast pump delivered to your house. (There is no out of pocket cost for one electric breast pump per pregnancy.)

BENEFICIO DE EXTRACTOR DE LECHE TRICARE

Marque esta casilla si desea recibir un extractor de leche eléctrico en su casa. (Sin ningún costo por un extractor de leche eléctrico por embarazo).

BENEFICIO DE EXTRACTOR DE LECHE COLORADO MEDICAID

Marque esta casilla si desea recibir un extractor de leche eléctrico en su casa. (Sin ningún costo por un extractor de leche eléctrico por embarazo).

Damage Waiver - $35.00 to be charged at final billing (optional)

Pediatrician or Clinic Name:

Nombre del pediatra o clínica:

Pediatrician or Phone Number:

Teléfono del pediatra o clínica:

Baby's Legal Name (Patient):

Nombre legal del bebé (Paciente):

Baby's Date of Birth (Patient):

Fecha de nacimiento del bebé (Paciente):

Your Cell Phone Number:

Su fecha de nacimiento:

Número de teléfono del padre:

Sponsor's Date of Birth:

Fecha de nacimiento del patrocinador:

Sponsor's Legal Name:

Nombre legal del patrocinador:

Número de seguridad social del patrocinador:

Teléfono Celular del tutor:

Mother's Legal Name:

Nombre legal de la madre:

Mother's Medicaid ID:

Medicaid de la madre ID:

Mother's Date of Birth:

Fecha de nacimiento de la madre:

Baby's Medicaid ID (if known):

Identificación de Medicaid del bebé (si se conoce):

Bili Blanket Rental - Place Order

1. Choose your insurance provider

2. Your Information

Hours