Need Help Contacting Your Insurance Rep? Reach Out to Us!

Please fill out form completely to ensure a timely process. We cannot process the order with out 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) 255-7882. 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.


If you would like us to contact your doctor to obtain your prescription information this will cause a delay (NO INTERNATIONAL Offices). It is always BEST and quickest if you already have the prescription. If we don’t have the correct phone number and fax number to your doctors office it will cause a delay as well.

If you have any questions, please call us at (866) 255-6779 or email us at If you have to leave a voice mail please note that we will call you back the same or next day. Thank you!

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  • I acknowledge I have not received a personal use breast pump & supplies (and/or replacement supplies) through this insurance policy or any other insurance policy for this pregnancy. I understand if I have received a breast pump & supplies (and/or replacement supplies) through another provider or insurance coverage this claim may be denied and I will be responsible for paying the full retail value of the breast pump & supplies (and/or replacement supplies) to The Breastfeeding Shop. Additionally, I understand I am ultimately responsible for any unpaid charges for the breast pump & supplies (and/or replacement) if my insurer denies the claim for any reason.

  • I acknowledge that I have access to The Breastfeeding Shop's Privacy, Rights & Responsibility as well as the Supplier Standards, which are available to me in the link below.

  • Use your mouse or finger to draw your signature above. Assignment of benefits and release of information: By signing this, I authorize my insurance company who is responsible for paying for my care to pay benefits on my behalf directly to The Breastfeeding Shop for any products or services that were rendered to me by The Breastfeeding Shop. I also authorize The Breastfeeding Shop to request, on my behalf, all public and private insurance benefits for products provided to me by The Breastfeeding Shop. I hearby authorize The Breastfeeding Shop to release my medical records to any person, organization, company and/or agency which is or may be 1. Involved in providing care for me or 2. liable for any portion of the payment of the charges for such products and services. I also acknowledge by signing this form that if my insurance company reimburses for replacement supplies that my signature means that I agree to receive those items with my initial breast pump order, such as replacement tubing, caps, locking rings, bottles, flanges & milk storage bags.