PMSI Pump Selection Form

Replacement Parts Order Form

IMPORTANT: Insurance only allows for one set of each item per order.

Step 1: Please make your selections from the options below. (1 pair/set per order)
Note: Spectra and Motif Luna utilize the same product design. You will be supplied according to stock on hand.

Step 2: Select your shipping preference

Step 3: Acknowledge terms and conditions on the final page and click "submit" to place your order!

NOTE: Replacment Parts may be ordered one month after previous orders.

Replacement Parts

Make Your Selections Below *

Breastshield/Flange (Select One Brand Only)

Medela (for all Medela pumps) Breastshield 2 each (Office Use=1,2)

Please select sizing below

$ Free Size options

Spectra and Motif Luna Breast shield 2 each (Office Use= 2,2)

Please select sizing below

$ Free Size options

Tubing (Select One)

Spectra and Motif Luna Tubing Item: MM012401 2each (Office Use= 2,2)

Quantity: 2 each

$ Free

Medela Pump in Style w/Max Flow Tubing. Item: 101040485 2each (Office Use= 1,2)

Quantity: 2 each

$ Free

Medela Symphony Tubing (for rental pump) 2each (Office Use=2,2)

Quantity: 2 each

$ Free

Bottles (Select One)

Spectra/Motif Bottles Item: MM011909 2pk (Office Use=1,2)

2 bottles per pack Locking ring, disc, and cap included

$ Free

Medela Bottles Item: 87130 2ea (Office Use=2.2)

2 bottles per order Locking ring, disc, and cap included

$ Free

Milk Storage Bags

Motif Pump and Store Breastmilk Storage Bags (90ct)

90 each per pack NOTE: Some policies do not offer coverage for storage bags. If not covered, this item will be removed from orders accordingly.

$ Free

Retail Best Sellers! (Use code: EXTRA10 at checkout)

Spectra Backflow Protectors (1ea) (MM011992)

Item is not insurance eligible.

$9.99 Quantity

Haakaa Generation 2 Silicone Breast Pump w/ Suction Base

Easy to use. No small parts. No assembly required. Simply suction to your breast and let the pump do the work for you as it draws your milk using suction.Size: 4oz

$17.99 Quantity

Motherlove Nipple Cream

Provide relief during your breastfeeding and pumping journey with Motherlove’s best-selling Nipple Cream.

$12.99 Quantity

Spectra Cooler Kit

Includes 2 bottles and cooling element.

$29.99

Medela Cooler Kit

Includes 4 bottles and cooling element.

$24.99

Shipping

Shipping

$ Free Shipping Options

Hold for pickup

Pickup at our office in Bellevue. M-F 10-4. You will be contacted when the order is ready.

$ Free

Enter coupon

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card Details (For Shipping and Add-Ons)
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Full Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

cityState

Zip Code
Confirm City *
For accurate tax calculation

Finalize Your Order

Agree to terms and place your order
I agree to Return Policy Terms*

Product Returns: By checking the following box, I understand that PMSI does not accept the return of *ANY* breast pump accessory once it has been opened and, due to their hygienic nature, pump accessories may not be returned to PMSI for any reason once opened. Please refer to the PMSI website for a full overview of our return policy: https://www.pacificmsi.com/warranty-information
I agree to Date of Service Terms*

Date of Service: I understand the "Date of Service" is the date in which equipment is provided to me. Orders placed at the end of a calendar month may be fulfilled the next month. I am responsible for notifying PMSI if my insurance is changing and will impact the claims process.
I agree to Start date and Frequency Guidelines*

Replacement parts can be ordered no sooner than one month after the purchase date of your pump. Subsequent replacement part orders must be separated by at least one month. Ordering replacement parts too soon (or from multiple suppliers) might result in a denied claim and a patient invoice.
I give permission for my insurance to be billed*

By clicking “submit” I am requesting PMSI to provide breast pump replacement parts to me and I request payment under my medical insurance to be made directly to PMSI. In the event my medical insurance does not make payment, I agree to be personally liable for all charges. I authorize any provider of my medical information to release any information necessary to determine services, benefits, and payment on my behalf.
HIPAA Guidelines*

I understand that PMSI will keep all personal information submitted on this form private as per HIPPA guidelines. I can view HIPPA guidelines at: https://www.pacificmsi.com/hipaa-policies
By clicking the submit button, I agree to terms & conditions*

Co-insurance, deductible, and taxes: I understand that my policy might be subject to co-insurance, deductible, or assigned sales taxes. These charges are determined by the insurance company and are a percentage of the allowable set forth by each payor. These charges are sent via invoice after the claim has been processed by insurance, if applicable. Questions regarding co-insurance or sales tax should be directed to the insurance provider.
By signing I agree to all terms. Please place my order. *

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Full Name*
Date of Birth*

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Replacement Parts

Finalize Your Order