To submit this form, please email it to managedcarefax@medline.com or fax it to 1-866-202-1563. Ensure all sections are completed, and include all necessary medical documentation. For any questions, you can call Medline at 1-877-791-0064 for assistance.

For this form, note that requests should be made within 30 days of the expected due date. Ensure the infant's date of birth is within six months to qualify. The form must be submitted in a timely manner for prompt processing.

The primary purpose of this form is to facilitate the request for an electric, nonhospital grade breast pump. It ensures mothers have access to necessary equipment for breastfeeding, promoting health and wellness for both mother and child. This form also serves as a documentation of medical necessity required by insurance companies for coverage purposes.

• 1. Member's name (mother): The full name of the mother requesting the breast pump.
• 2. Infant's DOB: The date of birth of the infant, if born.
• 3. Mother's Member's ID: ID number of the mother in the respective insurance plan.
• 4. Estimated due date: The expected due date of the infant.
• 5. Member's DOB: Date of birth of the mother.
• 6. Infant's Member ID: ID number for the infant in the insurance plan, if applicable.
• 7. Member's cell phone number: Contact number for the mother.
• 8. Member's name (infant): The name of the infant.
• 9. Member's shipping address: The address where the pump should be delivered.
• 10. City: City of the shipping address.
• 11. State: State of the shipping address.
• 12. ZIP code: ZIP code of the shipping address.
• 13. Member's email: Email address for communication regarding the Continuum of Care program.
• 14. Request: Type of breast pump requested.
• 15. ICD-10: Medical coding for the request.

Failing to submit this form can result in delays in receiving the breast pump. Without proper submission, the request may be denied by the provider, leading to potential complications in care. It is crucial to ensure all information is accurate and complete.

• Delays in receiving the pump: Inaccurate or incomplete submissions can delay the delivery of the necessary equipment.
• Denied requests: Submitting the form incorrectly may lead to denial by insurance or suppliers.
• Lack of medical documentation: Without proper submission, essential medical records may not be established.

• 1. For new mothers: New mothers can use this form to request a breast pump based on medical necessity.
• 2. For healthcare providers: Providers can utilize this request form to facilitate equipment needs for patients.
• 3. For insurance claims: The form can support claims filed with insurance for medical equipment.