Please fill out as much of this form as possible, so we can process your request as quickly as possible. Note: the name listed on this request must exactly match the name listed on your insurance card/plan, or we will be unable to validate coverage.
* = Required field
THINGS TO NOTE
Applicant MUST have a Medicaid plan, either straight MA or state-funded plans through HealthPartners, BluePlus or Medica. Applicants with private insurance are not eligible.
We work hard to get car seats to clients as soon as possible. Because of the high volume of requests, car seat deliveries may take up to three weeks after initial referral and deliveries are scheduled according to estimated due date.
If you are requesting a breast pump, please request a prescription from your provider. You can request that your provider fax the prescription to us at to our office at 612-353-6437 or give the prescription to us upon delivery of your breast pump. Breast pumps can be delivered or picked up.
We do our very best to fulfill every request. However, please contact our Doula Coordinator before submitting your request if it is for someone who is 32 weeks pregnant or beyond. Doula availability is very limited in those cases.