Complimentary Accesories Request

Request Form

First name

Last name

Phone

You need to be a patient at Inland Breastfeeding Center to receive the covered education and complimentary accessories.

Are you a patient at Inland Breastfeeding Center?

Yes

At this moment, only patients with UHC (United Healthcare), UMR and Cigna are eligible.

Do you have UHC, UMR or Cigna insurance?

Yes

What complimentary accessory you'd like to receive alongside the 100% covered Lactation Education provided through the Patient Portal?

Address where we should ship the items to (shipping next business day):

I understand that my insurance will be billed for provided support. There will be no copay, no deductible or no coinsurance applied as these services are covered at 100%.

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