Request an Appointment | Verify Insurance - Bayou City Breastfeeding

We’ll review your insurance and help you schedule your visit. Most families hear from us within one business day.

This form takes about 5 minutes to complete
Before you begin, please have::
• your insurance card
• your baby's birthdate (if already born)

Please note: Your form will not submit if you don’t fill in all the required fields marked with (REQUIRED).

Step 1: Let's Learn About You

Briefly describe your situation for us.(REQUIRED)

Contact Information

Gestational or Lactating Parent's Name

Legal Name (First and Last) (REQUIRED)

Email (REQUIRED)

Mobile Phone Number (REQUIRED)

Street Address

City

State

ZIP (REQUIRED)

Lactating Parent Date of Birth

General Information

Classes available

In Person Classes:

Houston Office
3100 Richmond Ave, Suite 302
Houston, TX 77098

💪Push it Real Good: Labor Smarter, Not Harder (Prepared Childbirth Class)
🧩The Breast Pump Puzzle Class

Virtual Classes:

🗺️The Breastfeeding Blueprint: A Breastfeeding Basics Class

Visit Information

In-Home Visit Notice:

Home visits include a travel fee and may have higher out-of-pocket costs.

For in home visits, where will the visit take place?

Address (street, city, zip)

Urgent Visit Notice:

For urgent concerns, we offer a virtual triage visit and can usually schedule within 72 hours.
Insurance verification may not be completed in time. If your plan is not verified or not accepted, you may be responsible for payment.

Preferred days/times

Any days/times that do NOT work?

Step 2: Insurance Information

General Insurance Information:

We are in-network with most major insurance plans
Coverage varies by plan. We’ll verify your benefits and email you a clear summary of any expected costs.

Tell us about your your Insurance

Aetna Plans

We are in-network with Aetna and work with most plans.
We will verify your insurance and send you an email with coverage details.
If you want more detail on how Aetna plans typically work with our services, you can review that here: Aetna Insurance Policies

BCBS Plans

We are in-network with many BCBS plans, including PPO and HMO.
All visits include a patient responsibility (out-of-pocket cost).
If you are looking for care with no out-of-pocket cost, we may not be the right fit.
For more details, visit: : BCBS Insurance Policies

Cigna (via Wildflower)

We work with many Cigna PPO plans through Wildflower, a program that manages lactation benefits.
Coverage requires approval through Wildflower before your visit. We handle this process and will email you once completed.
Initial visits may include a patient responsibility (out-of-pocket cost)
Cigna HMO plans are not accepted.
For more details, visit: Cigna/Wildflower Insurance Policies : Cigna/Wildflower

Curative Plans

We are in-network with most Curative plans and and most patients have little to no out-of-pocket cost for lactation visits.
We will verify your insurance and send you an email with coverage details.

Humana Plans:

We are in-network with Humana and work with most PPO plans.
Initial visits may include a patient responsibility (out-of-pocket cost)
We will verify your insurance and send you an email with coverage details.

Multiplan & PCHS Plans:

We work with many PPO plans that use the Multiplan or PCHS networks.
Visits may include a patient responsibility (out-of-pocket cost).

Sana Benefits:

We are in network with Sana Benefits
Initial visits may include a patient responsibility (out-of-pocket cost)
We will verify your insurance and send you an email with coverage details.

TRICARE West

We are in-network with Tricare West.
All visits include a patient responsibility (out-of-pocket cost).
If you are looking for care with no out-of-pocket cost, we may not be the right fit.
We will verify your insurance and send you an email with coverage details.

United Healthcare (UHC) and UHC Affiliated Plans

We are in-network with most United Healthcare plans and and most patients have little to no out-of-pocket cost for lactation visits.
We will verify your insurance and send you an email with coverage details.
For more details about how United Healthcare plans work with our services, visit: United Healthcare Insurance Policies

Health Share Plans

Visits are self-pay, and we provide a superbill for potential reimbursement.
For pricing, visit: Cash Pay Price List

Other Plans

Visits are self-pay if we are not in-network with your insurance.
We provide a superbill for potential reimbursement.
For pricing, visit: Cash Pay Price List

Out of Network Plans

Visits are self-pay if we are not in-network with your insurance.
We provide a superbill for potential reimbursement.
For pricing, visit: Cash Pay Price List

Insurance Billing For Lactation Services

For postpartum visits, we submit claims for both the parent and the baby. Both must be present for the visit.

Lactation Service Insurance Note: If the adult patient isn't pregnant, lactating, or inducing lactation, many insurers will not cover the cost. If your plan does not cover the visit, you will be responsible for paying out-of-pocket for your visit.

Check our Cash Pay Price List for timely payment discounts. We accept credit cards, debit cards and HSA/FSA cards.

Step 3: Scheduling Options

✅ Schedule Now (Fastest Option)

We’ll contact you to schedule your appointment.
A card is required to hold your spot.
Insurance will still be verified before your visit.
If your insurance is not accepted, you will need to pay out-of-pocket.

⏳ DELAYED OPTION - Wait for Insurance Verification First

We verify your insurance before scheduling.
This usually takes 1–2 business days.
Your appointment may be delayed based on verification timing.

Step 4: Tell us about your baby

Baby First Name

Baby A First Name

Baby B First Name

Baby C First Name

Baby's Last Name

Baby's Date of Birth (REQUIRED)

Baby's Due Date (REQUIRED)

Step 5: Help us verify your insurance

Parent's Insurance Card Front and Back (REQUIRED)*

Uploading your insurance card helps us verify your benefits faster. Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 MB.

Add file

Please upload a file

Thank you for uploading your insurance card

DoD Identification Number :(REQUIRED)

DoD Benefits Number (DBN) :(REQUIRED)

Member ID :(REQUIRED)

Group ID

Policy Holder Full Legal Name

Policy Holder Email Address

Policy Holder Mailing Address

Policy Holder Phone Number

Policy Holder Date of Birth (MM/DD/YYYY)

Policy Holder Employer (REQUIRED)*

Date This Policy Began (effective date)

Secondary Insurance Provider

Secondary Insurance Member ID

Secondary Insurance Group Number

Tell us about your Baby's Insurance

Let's gather some insurance details for your little one next.

Here's why we submit claims for both the parent and baby for our consultations:

1. Individual Care: Each consultation often means taking care of both you and your baby. This dual focus ensures the best possible care for everyone involved.

2. Quality Time: Our consultations usually extend beyond the duration of standard medical visits. Billing for both helps us provide you with the thorough attention you deserve.

Information for Baby's Coverage

If both parents are not on the same insurance policy, we will need policy information for both parents.

Insurance ID

Insurance Group

Other Parent's Date of Birth (or N/A) (REQUIRED)*

Baby's Insurance ID

Baby's Insurance Group

Policy Holder Information (for Baby's Insurance)

First

Last

Policy Holder Date of Birth

Policy Holder Phone Number

Policy Holder Mailing Address

Policy Holder's Employer

Baby's Insurance Cards (REQUIRED)*

Please upload front/back pictures of your baby's insurance card(s) Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 10 MB.

Add file

Please upload a file

Step 6: Submit your information

CONSENTS (ALL ARE REQUIRED FIELDS)

Insurance Related Consents (REQUIRED)*

If you are using insurance for your visit, you are agreeing to:

Allowing us to verify your insurance
Being responsible for any amounts not covered by your insurance
Having both the lactating parent and baby present at each visit (otherwise, the visit will be billed as self-pay)

I authorize Bayou City Breastfeeding to verify my insurance benefits and communicate with my insurance company or third-party administrators (such as The Lactation Network or Wildflower) as needed. I understand that I am responsible for any amounts not covered by my insurance, including required patient responsibility fees. I understand that both the lactating parent and baby must be present at the visit in order to bill insurance and if one is not present, the visit will be self-pay.

Self-Pay Consent (REQUIRED)*

I understand that I am choosing not to use insurance and will be responsible for payment for my visit. I also understand that I will have a $100 deposit for my first visit.

Consent for Out of Pocket Costs - Cigna (REQUIRED)*

I understand that my initial visit at Bayou City Breastfeeding will include a $45 out-of-pocket cost, even when using my insurance.

Consent for Out of Pocket Costs - BCBS/TRICARE (REQUIRED)*

I understand that all visits at Bayou City Breastfeeding will include out-of-pocket costs, even when using insurance (BCBS/TRICARE).I also understand that I will have a $100 deposit for my first visit.

Scheduling Before Verification (REQUIRED)*

I understand that if I choose to schedule before insurance verification, I will be responsible for payment if my insurance is not accepted or does not cover my visit.

Consent for Travel fees (REQUIRED)*

I understand that home visits include a travel fee that is not covered by insurance and will be my responsibility.

Payment Policies (REQUIRED)*
Please review our Payment Policies on our website.

I agree to the BCB Payment Policies.

✍️ By typing your full name in the signature field below, you are providing your digital signature. This has the same legal effect as a handwritten signature and confirms that you have read and agree to the information above.

Full Name for Signature (REQUIRED)

Your information will be encrypted.

Request an Appointment | Verify Insurance

We’ll review your insurance and help you schedule your visit. Most families hear from us within one business day.

Step 1: Let's Learn About You

Contact Information

General Information

Classes available

In Person Classes:

Virtual Classes:

Visit Information

Step 2: Insurance Information

General Insurance Information:

Tell us about your your Insurance

Aetna Plans

BCBS Plans

Cigna (via Wildflower)

Curative Plans

Humana Plans:

Multiplan & PCHS Plans:

Sana Benefits:

TRICARE West

United Healthcare (UHC) and UHC Affiliated Plans

Health Share Plans

Other Plans

Out of Network Plans

Insurance Billing For Lactation Services

Step 3: Scheduling Options

✅ Schedule Now (Fastest Option)

⏳ DELAYED OPTION - Wait for Insurance Verification First

Step 4: Tell us about your baby

Step 5: Help us verify your insurance

Tell us about your Baby's Insurance

Information for Baby's Coverage

Step 6: Submit your information

CONSENTS (ALL ARE REQUIRED FIELDS)

We’ll review your insurance and help you schedule your visit. Most families hear from us within one business day.

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