Electric Nonhospital Grade Breast Pump Request Form
This form is used to request an electric nonhospital grade breast pump for eligible mothers. It requires specific patient information and is intended for TennCare members. Complete the form and submit it for timely processing and delivery of the breast pump.
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How do I fill this out?
To fill out this form, gather the necessary patient information. Make sure to provide details for both the mother and the infant. Review the completed form to ensure all required fields are filled before submission.
How to fill out the Electric Nonhospital Grade Breast Pump Request Form?
1
Collect the required patient information.
2
Fill in the necessary fields accurately.
3
Review the form for completeness.
4
Save the completed form.
5
Submit the form via email or fax.
Who needs the Electric Nonhospital Grade Breast Pump Request Form?
1
New mothers who are TennCare members need this form to request a breast pump.
2
Infant caregivers looking to provide breastfeeding support need this form.
3
Medical practitioners ensuring patients receive necessary equipment need this form.
4
Health organizations assisting mothers with breastfeeding may require this form.
5
Insurance representatives processing claims related to breast pumps need this form.
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1
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2
Click on the edit option to access editing tools.
3
Make necessary changes to the form fields.
4
Review your edits for accuracy.
5
Download the edited form for submission.
What are the instructions for submitting this form?
To submit this form, send it via email to orders@amedadirect.com or fax it to 337-628-2240. Ensure that all fields are correctly filled out to avoid any delays. For any assistance, contact Medline at 1-877-791-0064.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, it's crucial to submit your request as early as possible to ensure timely delivery of the breast pump after the birth of your infant. Specific cut-off dates may vary based on patient eligibility and the provider's processes.
What is the purpose of this form?
The purpose of this form is to facilitate the request for an electric nonhospital grade breast pump. It ensures that eligible mothers have the necessary equipment for breastfeeding and promotes infant health. This process is made efficient by collecting all required information upfront.
Tell me about this form and its components and fields line-by-line.
- 1. Member's Name (Mother): Full name of the mother requesting the pump.
- 2. Infant's Birthdate: The birthdate of the infant for whom the request is made.
- 3. Member's ID (Mother): Identification number for the mother, issued by Amerigroup.
- 4. Estimated Due Date: Expected date of delivery for the infant.
- 5. Member's DOB (Mother): Date of birth of the mother.
- 6. Member's ID (Infant): Identification number for the infant, issued by Amerigroup.
- 7. Member's Phone Number: Contact number for the mother.
- 8. Member's Name (Infant): Full name of the infant.
- 9. Shipping Address: Address where the pump will 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 order.
- 14. Request: Specific request indicating the type of breast pump.
- 15. ICD-10: ICD-10 code related to the request.
- 16. Provider Name: Name of the medical provider prescribing the pump.
- 17. NPI Number: National Provider Identifier for the prescribing provider.
- 18. Provider Signature: Signature of the prescribing provider.
- 19. Today's Date: Date when the form is signed.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in receiving the breast pump, which could affect breastfeeding efforts. It is crucial to ensure all required fields are completed accurately and submitted on time.
- Delay in Pump Delivery: Without proper submission, mothers may experience significant delays in receiving necessary breastfeeding equipment.
- Interruption in Breastfeeding Support: Issues with the form can result in interrupted support for new mothers aiming to establish breastfeeding.
- Increased Stress for Mothers: Inaccurate or incomplete submissions can lead to increased stress for mothers who require this essential support.
How do I know when to use this form?
- 1. For New Mothers: New mothers who are TennCare members can use this form to request a breast pump.
- 2. Breastfeeding Support: This form is utilized by caregivers seeking to support successful breastfeeding practices.
- 3. Provider Assistance: Medical providers use this form to assist their patients in obtaining necessary breastfeeding equipment.
Frequently Asked Questions
How do I submit this form?
You can submit the form via email to orders@amedadirect.com or fax it to 337-628-2240.
What information do I need to fill out?
You will need to provide demographic details for both the mother and the infant, including contact information and ID numbers.
Can I edit the form after filling it out?
Yes, you can edit the form using the PrintFriendly editor before finalizing it for submission.
Is this breast pump available to all mothers?
This breast pump is specifically for mothers who are TennCare members.
How long does it take for the pump to be delivered?
The pump will be delivered upon notification of the baby's birth or upon successful processing of the request.
Who can assist me with this form?
You can call Medline at 1-877-791-0064 for assistance with filling out the form.
What if I make a mistake on the form?
It's best to review your form before submission to avoid mistakes; you can edit in PrintFriendly if needed.
What is included with the breast pump?
The pump includes a dual hygienikit, tubing, valve components, and bottles.
Can I get lactation support?
Yes, Ameda provides online lactation support and resources.
Where can I find breastfeeding tips?
Visit insured.amedadirect.com for access to breastfeeding tips and video resources.
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