Electric, Nonhospital Grade Breast Pump Request Form - Providers

Electric, Nonhospital Grade Breast Pump Request Form - Providers

https://providers.amerigroup.com Electric, Nonhospital Grade Breast Pump Request Form (in place of prescription) Submit your completed form via an em...

790KB Sizes 0 Downloads 0 Views

Recommend Documents

Breast Pump Request Form - UniCare
Complete with a Dual HygeiniKit without. BPA (includes two 36-inch tubes, tubing adapter/pump connector, two adapter cap

Breast Pump Form - Providers - Keystone First
Common brands include (but are not limited to):. □ Medela □ Ameda □ Evenflow □ Lansinoh □ Hygeia □ Spectra.

File name: Hospital Grade Electric Breast Pump. File code: UM.DME.06. Origination: 4/2005. Last Review: 07/2012. Next Re

Double Electric Breast Pump
The Viverity® TrúComfort Electric Breast Pump provides many of the features busy moms love. ○ 4 speed modes and 7 le

Breastfeeding Boutique. Boutique Hours. 402-815-1135 (phone). 707 N. 190th Plaza. *Mon – Fri: 9 am – 4 pm. 402-815-1

Breast Pump Rx Form
66 West Ave. Canandaigua, Ny 14424. Ph: 585.396.9970. Fax: 585.396.7264 www.canandaiguams.com. Electric Breast Pump Pres

Breast Pump Request Form - Ambetter from Coordinated Care
Pump Delive. Referral Subm. Contact STL Medical Sup. Phone: NOTE: Member Information. *Delivering to: *Mother's N. *Medi

Dual Channel Electric Breast Pump - Drive Medical
Descriptions. Gentlefeed+ is a double electric or battery-op- erated breast pump that is to be used when a baby would no

Evenflo Advanced Double Electric Breast Pump - Medline
May 19, 2015 - The Evenflo Advanced Double Electric Breast Pump is an electrically powered breast pump that uses negativ

Breast pump
EDWARD LASKER, OF CHICAGO, ILLINOIS. BREAST rumr. Application ?led August 2, 1928. Serial No. 655,245. My invention rela


Electric, Nonhospital Grade Breast Pump Request Form (in place of prescription) Submit your completed form via an email to [email protected] or fax to 337-628-2240. For assistance, call Medline at 1-877-791-0064. (Note: Ameda Direct facilitates Ameda and Medela breast pumps.) Please complete all patient information below or attach face sheet containing the demographic information. *Denotes a required field Member’s name (mother):* Infant’s birthdate (if baby has been born):* Member’s Amerigroup Washington, Inc. ID (mother):*

Estimated due date:*

Member’s DOB (mother):*

Infant’s Amerigroup ID:

Member’s phone number:*

Member’s name (infant):

Member’s shipping address:* City, State:*

ZIP code:*

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 Amerigroup. Pump will be delivered 30 days prior to baby’s estimated date of birth. Please mark the member’s breast pump choice below:

Ameda Finesse™ Pump

Ameda Finesse Ultra Pump

Complete with a dual hygienikit® milk collection kit 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 with custom fit breast flanges, reducing inserts, four white valves and two 4-ounce polypropylene bottles with tops), AC power adapter and built-in battery pack; two-year warranty.

Comes with everything included in the Ameda Finesse™ Pump plus: Dottie tote (a versatile shoulder bag), Cool 'N Carry tote (insulated carry bag, four additional four-ounce bottles with lock-tight lids, three cooling elements and milk storage guidelines card), two-pack sample of no-show premium disposable nursing pads and a two-pack sample of Store ‘N Pour milk storage bags.

 Medela Pump in Style Advanced starter set Includes two-phase expression technology with adjustable suction, one set of tubing, two breast shields, two valves, two connectors, two membranes, two 5-ounce bottles with lids and a power adapter.

Additional no-cost member benefits (applicable only to members receiving Ameda brand breast pumps):  Online library of breastfeeding tips and videos (Visit https://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

©2016 Medline Industries, Inc. All rights reserved. Ameda and Finesse are registered trademarks of Ameda, Inc. Medline is a registered trademark of Medline Industries, Inc. MKT1435315 / PDF / 23


March 2018

I, the undersigned, certify that the indicated prescribed item(s) is/are medically necessary for this patient’s well-being. The patient’s medical record contains information that 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 number (if applicable):

Provider signature:

Today’s date:

Page 2 of 2