Bright Start Breast Pump Prior Authorization Request Form Form

Breast Pump Authorization Form Date: Fax this completed form to 1-855-558-0488. Member information Mother’s name: Mother’s birth date: Member ID: Baby’s estimated due date: Baby’s birth date: Gestational age: Weight (grams or lb. oz.): Mother’s phone number: Alternate phone number and contact name if not the mother: Member’s email address: Mother’s address: Deliver pump to this address: Provider information Ordering provider’s name: Ordering provider’s NPI: Ordering provider’s signature: Ordering provider’s phone number:

Breast Pump Authorization Form Select pump type □ Manual __ Specific brand/product requested. This is the basic equipment for a breast-feeding mom to maintain adequate breast milk. It can meet the needs of a mom separated from her baby for short and irregular intervals. □ Basic double-sided, single-phase electric pump __ Specific brand/product requested. This equipment is designed to meet the breast-feeding needs of a mom whose baby is detained in the hospital for two to four weeks: • Who is separated from her baby regularly due to work or school. • Whose baby may be briefly and temporarily detained in the hospital with: – Jaundice (neonatal or physiologic). – Receiving antibiotics. • With a clinically significant breast engorgement. • With a breast abscess. • With mastitis. • With retracted or inverted nipples. • Whose nipples are cracked or have fissures. □ Neonatal intensive care unit (NICU)-level double-sided/ double-phase electric pump __ Specific brand/product requested. This equipment is designed to meet the breast-feeding needs of a mom whose baby is expected to be in the hospital for more than four weeks: • Who has cardiac anomalies or whose baby has cardiac anomalies. • Who has a multiple birth. • Whose baby is detained in the NICU. • Who gave birth prematurely at 32 weeks or less. • Who has a chronic or serious neonatal anomaly or condition. □ Preferred vendor for breast pump If you have questions about whether a patient qualifies for a breast pump, please call the Bright Start program at 1-833-669-7672. ACDE-18144205 www.amerihealthcaritasde.com