Breast Pump Order Form

Download the Breast Pump Order Form PDF

  • PART 1- COMPLETE PATIENT DEMOGRAPHICS


  • PART II- SELECT BREAST PUMP MODEL

    (*The Patient is responsible for any co-payments and deductibles that may be applied by your insurance plan. Our Customer Service Associate will advise you as to which Breast Pump your Plans benefit covers. If you wish a Breast Pump with more features, your Insurance Plan's reimbursement amount can be applied toward the purchase of the upgrade.)

    • Ameda Purely Yours Personal Double Electric Breast Pump
      This unit is a Dual Hygiene Milk Collection System and comes with 2 bottles, 2 Breast Flanges, tubing and DVD.

    • Ameda Purely Yours® Personal Double Electric Breast Pump with Tote & CustomFit™ Breast Flanges
      Comes with a large, all in one carry case, 4 bottles, Cool 'N Carry Tote, Custom Fit Breast Flanges, DVD.

    • Ameda Purely Yours Ultra

    • Medela PNS Starter Double Electric Breast Pump
      This unit comes in a carry case which includes 2 bottles, 2 shields, tubing, and a power pack.

    • Medela Accessory Starter Kit (Retail Item)
      30 Disposal Nursing Bra Pads, 2oz. Tube of Lanolin. For Tender Breasts, 20 Breast Milk Storage Bags, 20 Accessory Wipes, 5 Micro-Steam Bags.

    • Medela Pump In Style Tote

  • PART III- ASK YOUR PHYSICIAN TO WRITE A PRESCRIPTION FOR A DOUBLE ELECTRIC BREAST PUMP.

    ASSIGNMENT OF INSURANCE BENEFITS AND RELEASE OF INFORMATION: I hereby authorize my public and/or private insurance company or funding resource responsible for paying for my care, if applicable, to pay benefits on my behalf directly Northern Medical Equipment, for any products and services furnished to me by Northern Medical Equipment. I also authorize Northern Medical Equipment to request, on my behalf, all public and private insurance benefits for products and services provided to me by Northern Medical Equipment. I hereby authorize Northern Medical Equipment to release my medical records to any person, organization, company and/or agency which is or may be (1) involved in providing care for me or (2) liable for any portion of the payment of the charges for such products and services.

  • Note or Special Instructions: