Request a Breast Pump

Authorization for Insurance and Prescription Review

I authorize NuLife Medical Supplies to use the information I provide to review my identity, active insurance eligibility, the product-specific HCPCS E0603 breast-pump benefit, prescription requirements, and available equipment options. I also authorize NuLife to contact my insurer and healthcare provider for this review.

I understand that an eligibility or benefit response is not a guarantee of payment. No product, patient price, insurance amount, order, shipment, or claim is final until NuLife completes its review and provides the applicable written decision or quote.

I confirm that the information I provide, including whether insurance already provided a pump for this pregnancy or birth, is accurate to the best of my knowledge. I consent to electronic records, communications, and signatures for this request. Submitting this intake does not charge my card.

Agreement version: intake-authorization-2026-08-21-draft-2