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Patient Information

Patient Name*

First Last

Patient DOB*

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Expected Delivery Date*

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Address*

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Phone*

Email

Policyholder Name*

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Insurance Name*

Policy ID Number*

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Items Prescribed

Double Electric Breast Pump

Z39.1 Lactating Mother

Other

Length of need = 12 months. Use breast pump as needed to maintain or increase milk supply.

Enter Other Diagnosis / ICD-10 Code

Breast Pump Supplies

Breast Pump Supply Kit

Supply Kit Includes:
A4281 - Replacement Tubing - 24 ea.
A4282 - Replacement Battery Pack - 1 ea.
A4283 - Replacement Bottle Lid - 24 ea.
A4284 - Replacement Breast Shields - 24 ea.
A4285 - Replacement Bottle - 24 ea.
A4286 - Replacement Locking Ring - 24 ea.

Compression Socks / Stockings / Leggings - Qty 4

O22.01 - Varicose Veins 1st Trimester

O22.02 - Varicose Veins 2nd Trimester

O22.03 - Varicose Veins 3rd Trimester

Other

Compression Type

Socks

Thigh High Stockings

Leggings

Enter Other Diagnosis / ICD-10 Code

Shoe Size

Ankle Circumference

Calf Circumference

Bottom of Foot to Bottom of Knee

Thigh Circumference

Waist Circumference

Bottom of Foot to Gluteal Fold

Maternity Support Brace

M54.50 Other Lower Back Pain

Use brace daily to relieve low back pain during pregnancy and post-partum.

Belly Circumference

In Inches

Medical Post-Partum Recovery Garment

O26.72 Pubic Symphysis

O90.0 C-Section Wound

M62.0 Rectus Diastasis

O26.899 Round Ligament Pain

O22.1 Vulvar Varicosity

R10.2 Pelvic and Perineal Pain

O90.1 Episiotomy/Perineal Tear

O99.89 Puerperium Pain

Other

Other Diagnosis / ICD-10 Code

C-Section Dressing System

O90.0 C-Section Wound

Other

Other Diagnosis / ICD-10 Code

Reletex® by Reliefband® - Qty 1

O21.0 Hyperemesis Gravidarum

R11.0 Nausea

Use to treat vomiting and nausea due to pregnancy. Length of need = 9 months.

DVT Pump

Plexus DVT Prevention Device

Enter Diagnosis / ICD-10 Code. (Optional)

Enter Diagnosis / ICD-10 Code. (Optional)

Blood Pressure Monitor

Deluxe Automatic Blood Pressure Monitor, Upper Arm

Enter Diagnosis / ICD-10 Code. (Optional)

Enter Diagnosis / ICD-10 Code. (Optional)

Physician Information

Physician Name*

First Last

NPI*

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I certify that the above prescribed equipment is medically indicated and supports accepted standards of medical practice for this patient's condition.

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