FREE Mommy Care Kit

To keep you comfortable during these trying times, Mother Nurture Ultrasounds has partnered with TBS Medical to offer you the home therapy Mommy Care Kit. Plus, the Kit is likely covered by your insurance so there’s No Cost! To qualify for a no cost Kit, please fill out the form below. You do not have to be a client of Mother Nurture Ultrasound to apply.

(If Tricare use Benefits number in this field)
(If Tricare use DOD number in this field)

HCPC​: ​L0625 / L0642 / E0730 / A4595 / E0676 / E0603

Dx​ ​Code​: Z34.90 | NPI : 1134512072

By signing below I acknowledge that I have read and received a copy of: ​DME Supplier Standard Patient Rights & Responsibilities​.
Patient Acknowledgment & Authorization to Assignment of Benefits (PA/AOB)​: I request that payment of authorized insurance be made on my behalf to NDM and its Assigns (listed below) for products & services that they provide to me. I further authorize a copy of this agreement to be used in place of the original to release to payers any information needed to determine these benefits or compliance with current healthcare standards. I understand that I am financially responsible for my health insurance deductible, coinsurance, co-payments or non-covered services. I acknowledge receiving instruction, have demonstrated or verbalized my understanding in the proper use and care of the equipment or supplies described on this document today and will follow them. I acknowledge receipt & understand the company patient information privacy notice and that all information on this document is correct.

Signature is required.
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