BREAST PUMP PRESCRIPTION
Name of Mother*: ______________________________DOB: __________ Name of Baby*: ________________________________ DOB: _________ Address: ________________________________________________________________ Home Phone: _______________________ Cell Phone: ________________ Primary Insurer: ___________________________ Insurance #:______________ Secondary Insurer: _________________________ Insurance #:______________ *Benefits vary by insurer and plan, including by whom and for whom prescriptions must be written. MANUAL BREAST PUMP Manual Breast Pump (for short-term or occasional use) ELECTRIC BREAST PUMP Hospital Grade Electric Breast Pump (E0604) with Double Pump Kit Individual Electric Breast Pump (purchase pump) (E0603) Reason (check all that apply) Baby in NICU with expected stay greater than 72 hours (779.31) Difficult latch/suppressed latch (676.54) Mastitis (675.24) Inadequate milk production (676.54) Poor infant weight gain (783.41) Jaundice (774.31) Poor latch (676.84) Engorgement (676.24) Retracted nipple(s) (676.04) Cracked nipple(s) (676.14) Failure to establish effective breastfeeding pair (676.84) Other: ______________________________________ Date Needed ________________ Time Needed (if needed for discharge) ______________ Length of Need (Hospital Grade Electric Breast Pump only) (number of) months OR Indefinite / as long as breastfeeding _________________________________________________________________________________________________ AUTHORIZATION SIGNATURE: ___________________________________________________MD / DO / NP / CNM / PA Printed name: ___________________________________ NPI #: _______________ Address: _________________________________________________ _________________________________________________________ Phone #:_____________
Developed by the Physicians Committee for Breastfeeding in Rhode Island and the Rhode Island Breastfeeding Coalition, adapted by the Maryland Breastfeeding Coalition. This form functions as a prescription and letter of medical necessity for a breast pump and necessary accessories.