Get Submit Your Completed Form Via An Email To Managedcarefaxmedline

Filling out the Submit Your Completed Form Via An Email To Managedcarefaxmedline is a key step in requesting an electric, nonhospital grade breast pump. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by completing all required patient information fields. Ensure you provide the member’s name (mother) and infant’s date of birth if the baby has been born.
3. Fill in the mother’s member ID, estimated due date, and the mother's date of birth. Each of these fields is marked with an asterisk, indicating they are required.
4. Optional fields include the infant’s member ID, the member's cell phone number, the infant's name, and the member's shipping address. Please complete these fields if the information is available.
5. In the request section, specify the choice of electric breast pump. Make sure to select one option from the listed pumps.
6. Confirm that the member and infant meet the eligibility requirements. The baby must be due within 30 days or have been born within six months prior to the request date.
7. Complete the certification section by providing the ordering provider’s name, NPI number if applicable, and their signature. Also, include today’s date.
8. Once all sections are filled out, review your information for accuracy. You can then save changes, download, print, or share the completed form.

Submit your completed form via email to Managedcarefaxmedline for processing.