Welcome to Milk N Mamas Baby Ordering System

Would you like to upload a prescription for your patient or use our online prescription? *(Required)

Upload prescription

Issue prescription through online entry

RX Upload - Please upload prescription here:

Max. file size: 50 MB.

Equipment Needed

Gradient Compression Socks (A6530) Length of Need 99 (purchase)

Gradient Compression Socks Sizing

ICD 10 Diagnosis Code(s) *

Varicose Veins 1st Trimester (O22.01)

Varicose Veins 2nd Trimester (O22.02)

Varicose Veins 3rd Trimester (O22.03)

Edema (R60.9)

Other

ICD 10 Diagnosis Code(s) * Other:

Equipment Needed *

Pregnancy Support Band, 3-9 months (L0621) - Length of Need 99 (purchase)

Pregnancy Support Band Sizing

ICD 10 Diagnosis Code(s) *

Back Pain (M54.50)

Sciatic Pain (M54.30)

Posture (M54.89)

Equipment Needed *

Post Partum Recovery Garment, 1 week - 4 months (L2630) - Length of Need 99 (purchase)

Post Partum Recovery Garment Sizing

ICD 10 Diagnosis Code(s) *

Patient Information

Patient First Name(Required)

Patient Last Name(Required)

Patient Phone Numer(Required)

Please enter a valid phone number.

Patient Date of Birth(Required)

Patient Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Insurance Company Name(Required)

Insurance Member ID(Required)

For Tricare members please use Benefits Number (11 digits) or Sponsors Social.

Insurance Phone Number(Required)

This should be the Member's Services phone number.

Provider Information

Ordering Provider First Name(Required)

First

Ordering Provider Last Name(Required)

Last

Ordering Provider Credentials(Required)

Ordering Provider NPI #(Required)

Email (if you want copy for your records)

Consent(Required)

I certify that the above products are medically necessary and that the information provided is accurate to the best of my knowledge. By signing below, I acknowledge that I have obtained the patient’s authorization to release the above information and other medical information that may be disclosed. I certify that my decision to prescribe this recommended product was based solely based on my determination of medical necessity set forth herein.

Signature(Required)

Signature Date(Required)

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Welcome to Milk N Mamas Baby Ordering System

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