Breast Pump Form - Providers - Keystone First

Breast Pump Form - Providers - Keystone First

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: Key...

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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:

Weight:

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.

100KF - 1422 - 157

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