2015 DME one page faxsheet v2 - Medela Breastpumps by...
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To order your Medela breastpump covered by your health insurance, fax or email this form to: Patient information Patient name _________________________________ Patient’s date of birth___ /___ / _____ Expected due date or date of delivery___/___ / ____ Telephone # (_____) ___________________________ Email________________________________________ Shipping Address _____________________________ City____________________State____ Zip _________ Insurance carrier______________________________ ID # _________________________________________ Group # _____________________________________ Prescriber section Ordering licensed practitioner (please print) _____________________________________________ Signature ____________________________________ NPI #________________________________________ Date ________________________________________ Telephone # (_____) ___________________________ Diagnosis Code ______________________________ Medela Pump In Style Advanced On-the-Go Tote Breastpump All-in-one portable pump system including accessories in a stylish microfiber bag, with Medela’s patented 2-Phase Expression technology. 57063 | Suggested retail $299.00 You pay $ 67186 | Suggested retail $41.99 You pay $ 57062 | Suggested retail $299.00 You pay $ Medela Pump In Style Advanced Backpack Breastpump All-in-one portable pump system including accessories in a stylish microfiber bag, with Medela’s patented 2-Phase Expression technology. Medela Harmony TM Breastpump The best-selling manual pump. Featuring Medela’s patented 2-Phase Expression technology and an ergonomic handle for comfort. For occasional use only. Medela, Inc., 1101 Corporate Drive, McHenry, IL 60050 www.medela.com Medela, Pump In Style and 2 Phase Expression are registered trademarks of Medela Holding AG. Harmony is a trademark of Medela, Inc. 1548205 A 0715 © 2015 Medela, Inc. Printed in the USA. Visit medelabreastfeedingus.com for more! You may have other options for a breastpump that fi ts your lifestyle. Medela’s Pump In Style ® Advanced Breastpump Starter Set is fully covered by your insurance!* 57081 | Fully covered* You Pay $0 *Based on confirmed eligibility and benefits. Phone: 870-333-1230 Fax: 870-333-1233 Or visit us at one of these locations: Jonesboro – Rogers - Fayetteville - Cave City 150.00 ! 0 FREE ! 150.00 !
Transcript of 2015 DME one page faxsheet v2 - Medela Breastpumps by...
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To order your Medela breastpump covered by your health insurance, fax or email this form to:
Patient information
Patient name _________________________________
Patient’s date of birth___ /___ / _____
Expected due date or date of delivery___ /___ / ____
Telephone # (_____ ) ___________________________
Email________________________________________
Shipping Address _____________________________
City____________________State____ Zip _________
Insurance carrier ______________________________
ID # _________________________________________
Group # _____________________________________
Prescriber sectionOrdering licensed practitioner (please print)
_____________________________________________
Signature ____________________________________
NPI # ________________________________________
Date ________________________________________
Telephone # (_____ ) ___________________________
Diagnosis Code ______________________________
Medela Pump In Style Advanced On-the-Go Tote Breastpump
All-in-one portable pump system including accessories in a stylish microfiber bag, with Medela’s patented 2-Phase Expression technology.
57063 | Suggested retail $299.00You pay $
67186 | Suggested retail $41.99You pay $
57062 | Suggested retail $299.00You pay $
Medela Pump In Style Advanced Backpack Breastpump
All-in-one portable pump system including accessories in a stylish microfiber bag, with Medela’s patented 2-Phase Expression technology.
Medela Harmony TM Breastpump
The best-selling manual pump. Featuring Medela’s patented 2-Phase Expression technology and an ergonomic handle for comfort. For occasional use only.
Medela, Inc., 1101 Corporate Drive, McHenry, IL 60050 www.medela.com
Medela, Pump In Style and 2 Phase Expression are registered trademarks of Medela Holding AG.
Harmony is a trademark of Medela, Inc.
1548205 A 0715 © 2015 Medela, Inc. Printed in the USA. Visit medelabreastfeedingus.com for more!
You may have other options for a breastpump that fi ts your lifestyle.
Medela’s Pump In Style ® Advanced Breastpump Starter Set is fully covered by your insurance!*
57081 | Fully covered*You Pay $0
*Based on confirmed eligibility and benefits.
Phone: 870-333-1230 Fax: 870-333-1233
Or visit us at one of these locations: Jonesboro – Rogers - Fayetteville - Cave City
150.00 !
0 FREE !
150.00 !
