Get 855 843 8484

This guide provides step-by-step instructions on how to complete the 855 843 8484 form online for breast pump requests. This complete overview will assist users in providing accurate information required for processing their request efficiently.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the breast pump request form and open it for editing.
2. Indicate where the breast pump will be delivered by selecting either the 'Home' or 'Facility' option.
3. Enter the mother's name in the designated field.
4. Provide the baby's date of birth in the appropriate section.
5. Input the LHC Member ID number as requested.
6. Fill in the mother's date of birth.
7. Input the Medicaid number if applicable.
8. Complete the shipping address fields including unit/dept., city, state, and zip code.
9. Enter the main contact phone number.
10. If necessary, provide alternative contact information including name, phone number, and relationship.
11. For the physician information, fill in the referring physician's name and optional NPI.
12. Enter the physician's office phone number and fax number.
13. Select the breast pump option. In this case, the Medela Advanced Personal Double Pump.
14. Complete the referral submitted by section, entering the referring person's name, facility/provider, phone number, and email.
15. Review all entered information for accuracy before submission.
16. Save your changes, and choose to download, print, or share the completed form as needed.

Complete your breast pump request form online today!