NEW ORDER FORM

PLEASE MAKE SELECTION:

NAME:

First NameLast Name

DATE OF BIRTH:

Date

PHONE NUMBER:

Format: (000) 000-0000.

DUE DATE/BABY'S DOB

Date

ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

LANGUAGE:

EMAIL:

example@example.com

LANGUAGE:

INSURANCE COMPANY:

INSURANCE COMPANY MEMBER ID:

REPLACEMENT PARTS:

Other

I WOULD LIKE TO RECEIVE INSURANCE-COVERED MILK STORAGE BAGS

SELECT YOUR PRODUCT(S):

PLEASE SELECT YOUR PRODUCT(S):

I WOULD YOU LIKE TO VIEW OPTIONS THAT INCLUDE AN UPGRADE FEE?

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

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.

UPGRADE OPTIONS:

Spectra Breast Pump S1+: Upgrade Fee:

https://www.spectrababyusa.com/store/s1plus-/

$50.00

Spectra Synergy Gold SG Upgrade Fee:

https://www.spectrababyusa.com/store/spectra-synergy-gold/

$90.00

Spectra Synergy Gold SG Portable Upgrade Fee

https://www.spectrababyusa.com/store/spectra-sg-portable/

$105.00

Medela Freestyle Flex Breast Pump Upgrade Fee:

https://www.medela.com/breastfeeding/products/breast-pumps/freestyle-flex

$130.00

Medela Sonata Upgrade Fee:

https://www.medela.us/breastfeeding/sonata

$175.00

Total

Credit Card

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.

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

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

Equipment Needed:

DIAGNOSIS

Other

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:

Format: (000) 000-0000.

FACILITY PRACTICE FAX NUMBER:

Format: (000) 000-0000.

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

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 NAME:

First NameLast Name

REFERRAL SOURCE PHONE NUMBER:

Format: (000) 000-0000.

REFERRAL SOURCE EMAIL:

example@example.com

DAWN APPROVED SHIPMENT

PLEASE CHOOSE YOUR DELIVERY METHOD:

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.

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?

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.

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.

SIGNATURE DATE

Date

QUESTIONS AND/OR COMMENTS:

I AM A VITAL MILK EMPLOYEE

STATUS

ORDER RECEIVED:

ORDER ENTERED BY:

ORDER RECEIVED ON:

Date

INTAKE TEXT SENT

Date

INSURANCE VERIFIED

Rx RECEIVED

PRODUCT/DELIVERY CONFIRMED

VITAL MILK COMMUNICATION/TASKS

DELIVERY ASSIGNED TO

FAX 1st

Date

FAX 2nd

Date

FAX 3rd

Date

DATE OF MOST RECENT REMITTANCE

Date

DATE OF SHIPMENT/DELIVERY/PICK UP

Date

USPS TRACKING NUMBER

SERIAL AND/OR LOT NUMBER:

INCLUDE:

SHIPMENT NOTIFICATION TEXT SENT:

Date

CLAIM SUBMITTED

Date

CLAIM OUTCOME

Insurance & Misc. Docs

CLAIM NOTES

1st

Date

2nd

Date

3rd

Date

CLAIM NUMBER

PATIENT

CLIENT

INSURANCE

PRODUCT(S)

UPGRADE OPTIONS:

Credit Card

PRESCRIPTION

REFERRAL SOURCE

DELIVERY

TERMS & CONDITIONS

Order Details