breast pump prescription - Maryland Breastfeeding Coalition

breast pump prescription - Maryland Breastfeeding Coalition

BREAST PUMP PRESCRIPTION Date:_______________ Name of Mother*: ______________________________DOB: __________ Name of Baby*: ________________________...

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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 #:_____________

Fax #:________________

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.