Edit, Download, and Sign the Anthem HealthKeepers Plus Breast Pump Request Form
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How do I fill this out?
Filling out this form is simple and straightforward. You'll need to provide some essential details about the member and infant if applicable. Follow the detailed instructions below to ensure your form is completed accurately.
How to fill out the Anthem HealthKeepers Plus Breast Pump Request Form?
1
Enter the mother's name and contact details.
2
Provide the infant's birthdate and additional details if applicable.
3
Fill in the member's Anthem HealthKeepers Plus ID and DOB.
4
Complete any additional required fields such as shipping address.
5
Sign and date the form before submitting.
Who needs the Anthem HealthKeepers Plus Breast Pump Request Form?
1
Mothers who are members of Anthem HealthKeepers Plus and need a breast pump.
2
Healthcare providers prescribing a breast pump for their patients.
3
Insurance representatives processing claims for breast pump requests.
4
Lactation consultants assisting mothers with breastfeeding supplies.
5
Anthem HealthKeepers Plus members seeking additional breastfeeding support.
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How do I edit the Anthem HealthKeepers Plus Breast Pump Request Form online?
With PrintFriendly's PDF editor, you can easily make changes to the provided form. Add or update information directly within the fields. Save and download the edited document to retain a record of your updates.
1
Open the PDF form in PrintFriendly's editor.
2
Enter or update the required details within the designated fields.
3
Ensure all mandatory fields are completed accurately.
4
Add any necessary signatures or additional information.
5
Save the edited document and download it.
What are the instructions for submitting this form?
Submit the completed form via email to pumpprescriptions@edgepark.com or fax to 330-963-6172. Ensure all required fields are accurately filled out and signed by the provider. Check for any updates or additional instructions on the Anthem HealthKeepers Plus website. My advice is to double-check all provided information before submission to avoid any delays in processing your request.
What are the important dates for this form in 2024 and 2025?
Ensure to submit the form as soon as the baby is born or up to 30 days before the expected delivery date in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to request an electric nonhospital grade breast pump for members of Anthem HealthKeepers Plus. This form serves as both a prescription and request document for the breast pump, ensuring that members receive the recommended or preferred model in a timely manner. By providing all necessary information and fulfilling the requirements, the process of obtaining a breast pump is streamlined and convenient for both members and healthcare providers.
Tell me about this form and its components and fields line-by-line.
- 1. Member's name (mother): Enter the mother's full name.
- 2. Infant's birthdate: Provide the birthdate of the baby if already born.
- 3. Member's Anthem HealthKeepers Plus ID (mother): Enter the mother's Anthem HealthKeepers Plus ID number.
- 4. Member's DOB (mother): Enter the mother's date of birth.
- 5. Member's phone number: Provide a contact phone number for the member.
- 6. Member's shipping address: Enter the complete shipping address for the breast pump delivery.
- 7. City, State: Specify the city and state of the shipping address.
- 8. Estimated due date: Provide the estimated due date if the baby has not been born.
- 9. Infant's Anthem HealthKeepers Plus ID: Enter the infant's Anthem HealthKeepers Plus ID number if applicable.
- 10. Member's name (infant): Enter the infant's full name if already born.
- 11. ZIP code: Provide the ZIP code for the shipping address.
- 12. Member's email: Enter the member's email address.
What happens if I fail to submit this form?
Failure to submit this form could delay the delivery of the breast pump. This may result in the inability to obtain the recommended breastfeeding equipment on time.
- Delayed Delivery: Delay in receiving the necessary breastfeeding equipment.
- Incomplete Prescription: The form acts as a prescription ensuring the breast pump is medically necessary.
- Insurance Processing Delays: Delay in processing claims or approvals through Anthem HealthKeepers Plus.
- Missing Member Benefits: Not realizing additional no-cost member benefits offered.
How do I know when to use this form?
- 1. Pregnancy: Up to 30 days before delivery, the form helps in obtaining a breast pump.
- 2. Post-birth: Immediately after the baby is born, if a breast pump is required.
- 3. Healthcare Provider Prescription: When a healthcare provider prescribes a breast pump for a patient.
- 4. Insurance Approval: To process and approve the provision of a breast pump through insurance.
- 5. Member Support: For additional member support and to access no-cost benefits.
Frequently Asked Question
What is the purpose of this form?
This form is used to request an electric nonhospital grade breast pump for Anthem HealthKeepers Plus members.
Can I fill out this form online?
Yes, you can fill out this form online using PrintFriendly's PDF editor.
Do I need to provide the infant's details?
Yes, if the baby has been born, you need to provide the infant's details such as birthdate and Anthem HealthKeepers Plus ID.
How do I submit the completed form?
You can submit the completed form via email to pumpprescriptions@edgepark.com or fax to 330-963-6172.
Can I edit the form after filling it out?
Yes, you can edit the form using PrintFriendly's PDF editor before downloading and submitting it.
Is my signature required on the form?
Yes, the ordering provider's signature is required on the form.
What should I do if I have questions about the form?
If you have any questions, you can call Anthem HealthKeepers Plus Provider Services at 800-901-0020.
Can I request a different model of breast pump?
Yes, members have the option of selecting another type/model of pump.
When can the breast pump be delivered?
The breast pump may be delivered up to 30 days before delivery or upon notice that the baby has been born.
Who needs to complete the form?
The member or their healthcare provider needs to complete this form.
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