Get Lehans Baby Breast Pump Prescription Form 2016-2025

Filling out the Lehans Baby Breast Pump Prescription Form online can streamline the process of obtaining necessary equipment for breastfeeding. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Press the ‘Get Form’ button to obtain the prescription form and open it in your preferred editing tool.
2. Begin by filling in the patient information. Enter the patient's full name, date of birth, insurance ID number, and phone number in the respective fields.
3. Proceed to the prescription information section. Print the prescriber's name clearly and include their National Provider Identifier (NPI) number.
4. Select the type of breast pump required by marking the appropriate option: either 'Double Electric Breast Pump and Replacement Supplies' or 'Hospital Grade Breast Pump and Replacement Supplies.'
5. Indicate the length of need, which is typically set to 12 months.
6. Check the applicable diagnosis. This may include selecting Z39.1 for care of lactating mother or O92.79 for postpartum engorgement/milk retention. If other, please specify.
7. Ensure the prescriber provides their signature and the date. Note that stamped or co-signatures are not accepted.
8. Finalize the form by reviewing all the entered details for accuracy. Once confirmed, you may save the changes, download, print, or share the document as needed.

Complete your form online today to ensure a smooth process for obtaining your breast pump.