Breast Pump Insurance Order Form

Please fill out the form completely to ensure a timely process. We cannot process the order without a prescription. If you are expecting your physician to fax one over – please note that in the comments section, our fax number is (866) 430-7882. Please also note that the prescription MUST have a DX, i.e. (Z39.1), but it is up to your healthcare provider to determine which code/ dx is appropriate. Also, a LON i.e. (Length of Need – 99+ Months) AND E0603 (double electric breast pump) & Accessories. This is a secure form so your information cannot be viewed elsewhere. If information is left out it will delay the delivery. We are committed to shipping your orders as soon as possible and the more complete the form, the better we are able to do so. We do offer same day shipping if you need the breast pump urgently just call us to let us know @ (866) 255-6779. In most cases, once the pump is shipped, it will arrive the next day, as we ship from warehouses all over the USA, so we are able to get the breast pumps to you very quickly. Overseas orders do take a little longer.