Breast Pump Request Form (in place of Rx) Ways to submit your completed form: 1) via email: [email protected]
2) fax to 1-337-628-2240. For assistance, call Medline at 1-877-791-0064.
Please complete all patient information below or list the patient name, date of birth or attach face sheet containing the demographic information. Member’s name (mother):
Member’s UniCare Health Plan of West Virginia, Inc. (UniCare) ID (mother):
Member’s date of birth (mother):
Member’s name (infant):
Member’s UniCare ID (infant):
Infant’s birthdate or estimated due date:
Member’s shipping address: Member’s city:
Member’s phone number:
Member’s email (for Continuum of Care Program):
Request: electric breast pump (nonhospital grade), ICD-10: Z39.1 Requirements: Baby must be due within 30 days or have been born within no more than six months prior to request date. Mom and baby must be enrolled with UniCare. Pump will be delivered up to 30 days prior to infant’s estimated due date.
Please mark the member’s breast pump preference below: SELECT
Ameda Purely Yours Plus Pump
Ameda Purely Yours Ultra Pump
Ameda One-Hand Manual Breast Pump
Complete with a Dual HygeiniKit without BPA (includes two 36-inch tubes, tubing adapter/pump connector, two adapter caps, two silicone diaphragms, two pump bodies with standard size breast shields, CustomFit breast flanges, reducing inserts, four white valves and two 4 oz. polypropylene bottles with tops), AC power adapter and built-in battery pack.
Comes with everything included in the Ameda Purely Yours Pump kit plus: Dottie Tote — a versatile shoulder bag, CustomFit breast flanges, reducing inserts, Cool 'N Carry Tote (insulated carry bag, (six) 4 oz. bottles with lock-tight lids, (three) cooling elements, Milk Storage Guidelines Card), NoShow premium disposable nursing pads (2pk sample), Store ‘N Pour milk storage bags (2pk sample), and an AC power adapter.
Includes one-hand pump handle assembly, pump body with standard size (25mm) breast shield, white valve and 4 oz. bottle with top.
ADDITIONAL NO-COST MEMBER BENEFITS:
Online library of breastfeeding tips and videos; visit insured.amedadirect.com for more information Lactation support professionals online and a dedicated call center Regular communication from Ameda Direct with tips for success with breastfeeding
I, the undersigned, certify that the above prescribed item(s) is/are medically necessary for this patient’s well-being. The patient’s medical record contains information which supports medical necessity for the item(s) prescribed. In my opinion, the item(s) being prescribed is/are reasonable and necessary with reference to accepted standards of medical practice in treatment of this patient’s condition and has/have not been prescribed as convenience item(s). Ordering provider (first and last):
NPI # (if applicable):
©2016 Medline Industries, Inc. All rights reserved. Ameda and Purely Yours are registered trademarks of Ameda, Inc. Medline is a registered trademark of Medline Industries, Inc. UWVPEC-0600-17 March 2017