NEW ORDER FORM

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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(S)
THIS ORDER IS ONLY FOR REPLACEMENT PARTS AND/OR MILK STORAGE BAGS

YES
REPLACEMENT PARTS:

AMEDA MYA JOY PLUS REPLACEMENT MILK COLLECTION KIT: (4) Clear check valves, (4) Coated silicone diaphragms, (2) Silicone tubing, (2) Adapter caps, (1) Tubing adapter, (2) 25.0 mm flangesMEDELA REPLACEMENT MILK COLLECTION KIT: (2) 24mm PersonalFit PLUS breast shields(, 2) PersonalFit Flex Connectors with Membranes, (2) Bottles with Lids, (2) Pump in Style with MaxFlow TubingSPECTRA REPLACEMENT MILK COLLECTION: (2) 24mm Breast Flange: 24mm>(2) 5 oz. Spectra Wide Neck Milk Bottle with nipple, cap, disc, and cover, (2) Backflow Protector, (2) Duckbill Valve, (2) Tubing, (2) Adapter EndZOMEE Z2 REPLACEMENT MILK COLLECTION KIT: (2) 24mm Flex Breast Shield Flanges, (1) Tube set, (2) Diaphragms, (2) Diaphragm Caps, (2) Duckbill Valves, (2) Milk Bottles 140mlZOMEE FIT REPLACEMENT MILK COLLECTION KIT: (2) 25mm Fit Breast Shield, (2) Fit Collection Container Lid, (2) 6oz Fit Collection Container, (2) Fit Breast Shield Body, (2) Fit Diaphragm, (2) Fit Duckbill ValveOther
I WOULD LIKE TO RECEIVE INSURANCE-COVERED MILK STORAGE BAGS*

YESNO
SELECT YOUR PRODUCT(S):
PLEASE SELECT YOUR PRODUCT(S):*

Ameda ® GLOAmeda ® Mya Joy Plue with Deluxe ToteMedela ® Pump In Style MaxFlowSpectra ® S2+Spectra® S9+Spectra® Handy Plus Manual Breast PumpZomee ® Mother's Nature W1Zomee ® Z2 with Travel BundleZomee® Z2 with Hands Free CupsOther
I WOULD YOU LIKE TO VIEW OPTIONS THAT INCLUDE AN UPGRADE FEE?

YES
UNFORTUNATELY, MASSHEALTH MEMBERS ARE NOT ELIGIBLE TO SELECT AN UPGRADE.

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.
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

VIEW COMPARISON CHART
NEW OPTION!

Zomee Mother's Nature W1

WEARABLE BREAST PUMP
- Spectra® S2+ comes with 24mm and 28mm flanges
- Spectra® 9+ comes with 24mm flanges
- Zomee® Z2 w/Travel Bundle comes with 21mm and 24mm flanges
- Zomee® Z2 w/Hands Free Collection Cups comes with 21mm and 24mm flanges
- Ameda® Mya Joy Plus w/Deluxe Tote comes with 25mm, 28.5mm flanges
- Ameda® Glo comes with 24mm flange and 17mm, 19mm, 21mm soft flange inserts
- Medela ® Pump In Style Max Flow comes with 24mm and 21mm flanges
- Medela ® Pump In Style Pro comes with 24mm and 21mm flanges
- Zomee ® Fit comes with 25mm flange and 17mm and 21mm soft flange inserts
- Zomee ® Mother's Nature W1 comes with 24mm flange and 15mm,17mm, 19mm and 21mm soft flange inserts
Please let us know if you would like to receive a flange/breast shield size that is NOT listed above, we carry Maymom flanges and inserts ranging from 10mm-36mm that are compatible with Ameda, Medela, Spectra and Zomee breast pumps.
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-A4288 QTY: 2 each), as needed for 12 months.Electric breast pump, (E0603), as needed for 12 months.Manual breast pump, (E0602), as needed for 12 months.Replacement milk collection for use with dual electric breast pump (A4281-A4287 QTY: 2 each), as needed for 12 months.Tubing for breast pump, replacement (A4281-QTY: 2), as needed for 12 months.Adapter for breast pump, replacement (A4282-QTY: 2), as needed for 12 months.Cap for breast pump bottle, replacement (A4283-QTY: 2) , as needed for 12 months.Breast shield and splash protector for use with breast pump, replacement (A4284-QTY: 2), as needed for 12 months.Polycarbonate bottle for use with breast pump, replacement (A4285-QTY:2), as needed for 12 months.Locking ring for breast pump, replacement (A4286-QTY:2), as needed for 12 months.Milk storage bags (A4287-QTY 360), as needed for 12 months.Valve for breast pump, replacement (A4288-QTY:2), as needed for 12 monthsOther
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:
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
Insurance plans will only cover 1 electric breast pump per pregnancy/birth. Have you received an electric breast pump during this pregnancy or after your baby was born?*

YESNO
ABN (Advance Beneficiary Notice of Non-coverage): Since insurance only covers 1 electric breast pump per pregnancy/birth; I understand that I will be fully responsible for the payment of this breast pump, replacement parts and/or milk storage bags if I have received or ordered these product(s) from another provider.*

YES
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*

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QUESTIONS AND/OR COMMENTS:
I AM A VITAL MILK EMPLOYEE

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

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INTAKE TEXT SENT

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INSURANCE VERIFIED

YESNON/A
Rx RECEIVED

YESNON/A
PRODUCT/DELIVERY CONFIRMED

YESNON/A
VITAL MILK COMMUNICATION/TASKS
DELIVERY ASSIGNED TO

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