Breast Pump Form Fax to 1-866-405-7946 Do not fax before delivery. Mother’s name: Mother’s birth date: Baby’s birth date: Mother’s phone number:
Keystone First ID#: Gestational age:
Alternate phone number:
Mother’s address: Address to deliver pump: Ordering physician’s signature and phone number (please print): If you have a brand or pump type preference please specify on this form.
Common brands include (but are not limited to): □ Medela □ Ameda
□ Evenflow □ Lansinoh □ Hygeia □ Spectra
Select the type of pump: □ Manual
This type of pump: • Is the basic equipment for a breast-feeding mother to maintain adequate breast milk. • Meets the needs of a mother separated from her baby for short and irregular intervals.
□ Basic double-sided, single-phase electric pump This type of pump is:
• Designed to meet the breast-feeding needs of mothers separated from their babies on a regular basis due to work or school. • For babies who may be briefly and temporarily detained in the hospital (e.g., for jaundice (neonatal or physiologic) or to receive antibiotics). • Indicated when the following conditions are present in the breast-feeding mother: ̓̓ Clinically significant breast engorgement. ̓̓ Breast abscess. ̓̓ Mastitis. ̓̓ Retracted/inverted nipple. ̓̓ Nipples displaying cracks/fissures.
□ NICU level double-sided/double-phase electric pump This type of pump is:
• Indicated when there are cardiac anomalies in the baby or mother. • For multiples. • For babies detained in the NICU. • For preemies (32 weeks or less). • Indicated when there are other chronic or serious neonatal anomalies or conditions. Attention: Electric pumps are durable and built to last. Instruct members to handle with care and keep the pump clean, dry and stored in a safe place. Keystone First will approve an electric breast pump ONLY once/per member. Members will NOT get a new pump with each baby. If the equipment malfunctions, members are to notify the manufacturer for repair options. Please advise members to keep the original shipping box for potential repairs.
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