Breast Pump Prescription Form - Lehan Drugs

Breast Pump Prescription Form - Lehan Drugs

Lehan Breast Pumps 1407 South Fourth Street DeKalb, Illinois 60115 Phone: 815.758.0911 Fax: 866.509.3169 www.lehanbreastpumps.com Breast Pump Prescr...

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Lehan Breast Pumps 1407 South Fourth Street DeKalb, Illinois 60115 Phone: 815.758.0911 Fax: 866.509.3169 www.lehanbreastpumps.com

Breast Pump Prescription Form Patient Information Patient Name:___________________________________________________ Patient DOB:____________________________________________________ Patient Insurance ID#: _____________________________________________ Patient Phone #:_________________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Prescription Information Prescriber’s Name (Please Print):_________________________________________ Prescriber’s NPI #:______________________________________________________ Equipment: Double Electric Breast Pump and Replacement Supplies Hospital Grade Breast Pump and Replacement Supplies Length of Need: 12 months Diagnosis (Check Applicable): Z39.1 – Care of lactating mother O92.79 – Postpartum engorgement/Milk retention Other, please specify: Doctor Signature:______________________________________ Date:_____________ ***No stamped or co-signatures accepted***

FAX FORM TO: (866) 509-3169