Mother's First Name Mother's Last Name Mother's Date of Birth
Child's First Name Child's Last Name Child's Date of Birth
Address State Zip Code Telephone
First Name Last Name Relationship Date of Birth
Primary Insurance Member ID# Group ID#
Secondary Insurance Member ID# Group ID#
Z39.1 Breastfeeding/Lactating Mother779.31 Baby in NICU with expected stay greater than 72 hrs676.54 Difficult latch/suppressed latch675.24 Mastitis676.54 Inadequate milk production676.84 Poor latch676.04 Retracted Nipples676.14 Cracked Nipples676.84 Failure to establish effective breastfeeding
E0603 Double Electric Breast Pump (purchase)E0604 Hospital Grade Breast Pump (Prior Authorization)E0602 Manual Breast Pump
Physician’s Name (Print) Physician Signature NPI#
Patient Signature Date Witness
I have read and understand the terms and conditions provided on the back of this form: Supplier Standards, Release of Liability, Agreement to Pay, Patient Bill of Rights, and Patient Responsibilities. My signature confirms that I have received the above ordered item(s).
Please fax or upload a copy of front and back of insurance cards
Please fax a copy of front and back of insurance cards
