We are here to help you process your request for your new personal use breast pump! The information we collect on this form is required for insurance benefit confirmation and the processing of your breast pump order.
In preparation of your baby’s arrival, we confirm your insurance breast pump benefit ahead of time. We then contact you to assist you with your breast pump selection and confirm your insurance covered breast pump.
In addition to completing this form, a prescription for an electric breast pump must be issued by your healthcare provider. If you have a prescription, please upload it with this form. A prescription can also be faxed or emailed to us. Our Fax number is 888-606-8425. Once we receive your completed order and prescription, we promptly route your breast pump for delivery! Our order process is seamless. Remember we are here to help; you may call us for complete assistance with your order process 844-MILK-MOM.