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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
S (ankle) 6.5-8.5 in (calf) 11-16.5 in
M (ankle) 8-10 in (calf) 12-17.5 in
L (ankle) 9-11.5 in (calf) 13-19 in
XL (ankle) 11-15 in (calf) 17-23 in
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
XS (waist) 24-32 in (pre-preg pant size) 00-0
S (waist) 33-40 in (pre-preg pant size) 2-4
M (waist) 41-48 in (pre-preg pant size) 6-12
L (waist) 49-52 in (pre-preg pant size) 14-18
XL (waist) 53-62 in (pre-preg pant size) 20-26
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
XS (waist) 24-26 (hips) 34-36 (pre-preg pant size) 00-2
S (waist) 27-29 (hips) 37-39 (pre-preg pant size) 4-6
M (waist) 30-32 (hips) 40-42 (pre-preg pant size) 8-10
L (waist) 33-36 (hips) 43-45 (pre-preg pant size) 12-14
XL (waist) 37-39 (hips) 46-49 (pre-preg pant size) 16-18
2X (waist) 40-44 (hips) 50-54 (pre-preg pant size) 20-22
ICD 10 Diagnosis Code(s) *
Pubic Symphysis (026.72)
Perineum Pain (R10.2)
C-Section Wound (090.0)
Rectus Diastasic (M62.0)
Round Ligament Pain (026.899)
Swelling/Edema (090.89)
Pelvic Joint Pain (R10.2)
Vulvar Varicosity(022.1))
Episiotomy/Perineal Tear (090.1)
Pelvic Girdle Pain (099.89)
Post-Op Pain (099.89)
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)
MM slash DD slash YYYY
Patient Address
(Required)
Street Address
Address Line 2
City
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Iowa
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Louisiana
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Massachusetts
Michigan
Minnesota
Mississippi
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Montana
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New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
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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)
Please Select
CNM
CPM
DO
MD
NP
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)
MM slash DD slash YYYY
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