Breast Pump Request Form - Ambetter from Coordinated Care

Breast Pump Request Form - Ambetter from Coordinated Care

INTERNAL Breast Pump Request Form Contact STL Medical Supply Phone: 855-855 855-8484 – Fax: 877-219 219-6077 – Email: [email protected] Hours...

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INTERNAL Breast Pump Request Form Contact STL Medical Supply

Phone: 855-855 855-8484 – Fax: 877-219 219-6077 – Email: [email protected] Hours of operation: MM-F 8:30am-5:30pm 5:30pm CST NOTE: Referrals placed outside normal business hours will be processed the next business day.

Member Information (please enter the address where the breast pump will be delivered) : *Delivering Delivering to:

☐ Home or ☐ Facility

(Member Member must be less than 30 days from expected due date or have delivered within the last 6 months to receive a breast pump. pump.)

*Mother’s Mother’s Name: N

*Baby Baby Date of Birth Birth:

*Medicaid Medicaid #:

*Mother Mother Date of Birth:

**Shipping Shipping Address: Unit/Dept.: *City: *

*State:

*Zip: Zip:

*Main Contact Phone #:

Alt. Contact Name:

Alt. Contact Phone #:

Alt. Contact Relation:

Physician Information: Referring Physician:

NPI (optional):

Physician Office Phone #:

Physician Fax #:

Hygeia QTM Breast Pump w/ Tote Bag & Personal Accessory Set FEATURES  Hospital-Grade Hospital Grade Performance  Independently adjustable adjustable speed & suction controls to mimic baby’s unique suckling patterns  Allows for double or single pumping  All pump parts that come into contact with breast milk are BPA/DEHP free

INCLUDES  Electric Hygeia Q TM breast pump  AC Adapter Power Supply  Basic Personal Accessory Set (PAS)  Basic Tote: Insulated tote holds the pump and all personal accessory components  1-Year Year Limited Warranty

Pump Delivery Method (Please select the option based on the criteria listed below) :

☐ ☐

Standard Delivery  No significant mother/baby separation  No feeding difficulties  Infant without complications Next Day Delivery  Mother/baby separation  Significant feeding difficulties  NICU baby

Referral Submitted By: *Referring Referring Name:

*Referring Referring Contact Phone #: