NEW ORDER FORM

PLEASE MAKE SELECTION:

I AM SUBMITTING AN ORDER FOR MYSELFI AM SUBMITTING A REFERRAL ORDERI AM A LICENSED HEALTHCARE PROVIDER
PATIENT
CLIENT
NAME:*

First NameLast Name
DATE OF BIRTH:*

MonthDayYear
Date
PHONE NUMBER:*
DUE DATE/BABY'S DOB*

MonthDayYear
Date
ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
LANGUAGE:
EMAIL:
example@example.com
INSURANCE
INSURANCE COMPANY:
INSURANCE COMPANY MEMBER ID:
PRODUCT SELECTION
VIEW COMPARISON CHART
SELECT YOUR PRODUCT(S):
NEW OPTION!

AMEDA GLO

WEARABLE BREAST PUMP
PLEASE SELECT YOUR PRODUCT(S):

AMEDA GLOAMEDA MYA JOY PLUS W/DELUXE TOTESPECTRA S2+SPECTRA S9+ZOMEE FITZOMEE Z2 W/TRAVEL BUNDLEZOMEE Z2 W/HANDS FREE COLLECTION CUPSMEDELA PUMP IN STYLE MAX FLOWMANUAL BREAST PUMPMILK STORAGE BAGSREPLACEMENT PARTSUPGRADE MODELOther
Please note that Masshealth members are NOT eligible to select an upgrade model. According to Medicaid Policy, Durable Medical Equipment (DME) suppliers cannot charge a MassHealth member an upgrade fee for non-covered features or components, even if the member agrees to pay extra, as the capped rental payment is inclusive of all costs for effective use of the equipment.
WOULD YOU LIKE TTO VIEW OPTIONS THAT INCLUDE AN UPGRADE FEE?

YES
I understand that my health benefit plan makes payment based upon its allowance for covered standard items meeting medical needs. At an additional cost to me, I have chosen to upgrade from a covered standard item to a deluxe item, which may include additional features not covered under my current member benefits. I have been offered the following 100% insurance-covered standard models: Medela Pump In Style MaxFlow, Spectra S2+, Spectra 9+, Ameda Mya Joy Plus, Zomee Z2 and Unimom Minuet LCD. Instead of the available standard item, I choose to upgrade to a deluxe item. In choosing to upgrade to a deluxe item, I understand that I am responsible for the difference in cost between the retail price of the deluxe item and the retail price of the standard item.*

YES

PRESCRIPTION
IF YOU HAVE A PRESCRIPTION, PLEASE UPLOAD IT HERE OR FAX IT DIRECTLY TO VITAL MILK. FAX NUMBER 855-543-8942

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IF YOU DO NOT HAVE A PRESCRIPTION, WOULD YOU LIKE US TO CONTACT YOUR PROVIDER AND REQUEST ONE?

YES
Equipment Needed:

Electric breast pump (E0603), Milk storage bags (A4287-QTY: 360 bags) and Replacement parts (A4281-A4286 QTY: 2 each), as needed.Electric breast pump, (E0603)Manual breast pump, (E0602)Replacement milk collection for use with dual electric breast pump (A4281-A4286 QTY: 2 each), as needed.Tubing for breast pump, replacement (A4281-QTY: 2)Adapter for breast pump, replacement (A4282-QTY: 2)Cap for breast pump bottle, replacement (A4283-QTY: 2)Breast shield and splash protector for use with breast pump, replacement (A4284-QTY: 2)Polycarbonate bottle for use with breast pump, replacement (A4285-QTY:2)Locking ring for breast pump, replacement (A4286-QTY:2)Milk storage bags (A4287-QTY 360) , as needed.Other
DIAGNOSIS

Z39.1 Encounter for care and examination of lactating motherZ33.1 Encounter for supervision of normal pregnancy, unspecified trimesterZ34.83 Encounter for suprvsn of normal pregnancy, third trimesterOther
ORDERING PROVIDER NAME:

First NameLast Name
PLEASE PROVIDER THE NAME AND CONTACT INFORMATION FOR YOUR PRENATAL CARE PROVIDER.
ORDERING PROVIDER NPI:
FACILITY PRACTICE NAME:
PROVIDER EMAIL:
example@example.com
PRACTICE PHONE NUMBER:
FACILITY PRACTICE FAX NUMBER:
I certify that the above products are medically necessary and that the information provided is accurate to the best of my knowledge. By signing below, I acknowledge that I have obtained the patient’s authorization to release the above information and other medical information that may be disclosed. I certify that my decision to prescribe this recommended product was based solely based on my determination of medical necessity set forth herein. Provider Electronic Signature

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If you complete this section and are licensed to prescribe durable medical equipment, you DO NOT have to submit a prescription in any other format. Thank you for referring you patient to Vital Milk!
REFERRAL SOURCE
REFERRAL SOURCE NAME:

First NameLast Name
REFERRAL SOURCE PHONE NUMBER:
REFERRAL SOURCE EMAIL:
example@example.com
DAWN APPROVED SHIPMENT

YES
DELIVERY
PLEASE CHOOSE YOUR DELIVERY METHOD:
*The Certified Lactation Counselor (CLC) Delivery service is currently available in Hampden, Hampshire, Franklin and parts of Suffolk, Essex, Middlesex and Suffolk counties. You can choose this option if you want to meet with a CLC and receive personal instruction on how to set up and operate your breast pump. During this visit, we'd also be happy to answer any questions you may have pertaining to lactation and pumping.
TERMS & CONDITIONS
I acknowledge receipt and understanding of the following documents: Client Bill of Rights & Responsibilities, Medicare DMEPOS Supplier Standards, Notice of Privacy Practices, Complaint/Grievance Process, Return, Exchange & Warranty Services and Contact Information & Service Availability. I authorize Vital Milk to bill my insurance company for the electric breast pump that I have selected above. The Healthcare Common Procedure Coding System (HCPCS)code for an electric breast pump is E0603. I understand that my health plan only covers 1 breast pump per pregnancy and if I receive a breast pump from another supplier, I will be responsible for the retail price of the breast pump I have selected above. I authorize Vital Milk to contact me in the future, via telephone, email, mail or other means of communication, regarding ordering my durable medical equipment order. Assignment of Benefits (AOB): I request payment of authorized Medicare, Medicaid or private insurance benefits to me or on my behalf be made to Vital Milk for any services/products furnished to me by Vital Milk. Medical Release: I authorize any holder of medical information about me to release to Medicare, Medicaid or private insurance only in regards to information needed to determine these benefits or benefits for related services.*

YES
The following documents are also always accessible to you on our website: vitalmilk.com

Client Bill of Rights & Responsibilities

Medicare DMEPOS Supplier Standards

Notice of Privacy Practices

Complaint/Grievance Process

Return, Exchange & Warranty Services

Contact Information & Service Availability
Have you already received an insurance-covered breast pump during this pregnancy or after you gave birth?*

YESNO
By signing my name below, I certify that I have read the above information. Any questions concerning these statements have been discussed. My signature also certifies my understanding of and agreement with the above statements.*

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SIGNATURE DATE*

MonthDayYear
Date
QUESTIONS AND/OR COMMENTS:
I am a Vital Milk Employee

YES
Order Details
STATUS
ORDER RECEIVED:
ORDER ENTERED BY:
ORDER RECEIVED ON:

MonthDayYear
Date
INTAKE TEXT SENT

MonthDayYear
Date
INSURANCE VERIFIED

YESNON/A
Rx RECEIVED

YESNON/A
PRODUCT/DELIVERY CONFIRMED

YESNON/A
VITAL MILK COMMUNICATION/TASKS
DELIVERY ASSIGNED TO

CAPREDAISYDAWNEUGENIALOMELISSA
FAX 1st

MonthDayYear
Date
FAX 2nd

MonthDayYear
Date
FAX 3rd

MonthDayYear
Date
DATE OF MOST RECENT REMITTANCE

MonthDayYear
Date
DATE OF SHIPMENT/DELIVERY/PICK UP

MonthDayYear
Date
USPS TRACKING NUMBER
SERIAL AND/OR LOT NUMBER:
INCLUDE:
SHIPMENT NOTIFICATION TEXT SENT:

MonthDayYear
Date
CLAIM SUBMITTED

MonthDayYear
Date
CLAIM OUTCOME

PAIDDENIEDRESUBMITTEDPARTIALLY PAIDOTHERDONATIONPRIORITY FOLLOW UP
Insurance & Misc. Docs

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CLAIM NOTES
1st

MonthDayYear
Date
2nd

MonthDayYear
Date
3rd

MonthDayYear
Date
CLAIM NUMBER
Should be Empty:

PATIENT

CLIENT

INSURANCE

PRODUCT SELECTION

Credit Card

PRESCRIPTION

REFERRAL SOURCE

DELIVERY

TERMS & CONDITIONS

Order Details