Bilibee Request – Neb Doctors

Completion of this form is required to initiate your request for the rental of a BiliBee phototherapy unit.

PATIENT INFORMATION
Patient's First Name*
Patient's Last Name*
Patient's Date of Birth*
MM slash DD slash YYYY
Patient's Sex*
- Male
- Female
Patient's Street Address*
Patient's Street Address Line 2
City*
State*
Zip*
PARENT/GUARDIAN'S INFORMATION
Parent/Guardian's First Name*
Parent/Guardian's Last Name*
Address is the same as Patient's*
- Yes
- No
Street Address*
Street Address Line 2
City*
State*
Zip*
Cell Phone*
Email*
Does the child have active or pending Medicaid coverage? (Mother or Sibling must be on Medicaid)
- Yes
- No
Please upload a copy of your insurance card. (The insurance plan to which the child will be added)*
Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 32 MB.
Please upload a copy of your Phototherapy Rental Agreement
Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 32 MB.
Additional documentation (one file per upload)
Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 32 MB.
Additional documentation (one file per upload)
Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 32 MB.
Will you be returning this device to a different location?
- Yes
- No
Facility Name
POLICIES AND ACKNOWLEDGEMENT
To rent a phototherapy device you must agree to receive communications from Neb Doctors via text/SMS. Message and data rates may apply. Neb Doctors will not share this information.
- I Accept
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PATIENT INFORMATION