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Breast Pumps at Dartmouth Medical Services
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Breast Pump Order Form

  • PART 1- COMPLETE PATIENT DEMOGRAPHICS


  • PART II- SELECT BREAST PUMP MODEL

    (*The Patient is responsible for any co-payments and deductibles that may be applied by your insurance plan. Our Customer Service Associate will advise you as to which Breast Pump your Plans benefit covers. If you wish a Breast Pump with more features, your Insurance Plan�s reimbursement amount can be applied toward the purchase of the upgrade.)

    • Medela Pump in Style Starter Kit

    • Medela Freestyle (Upgrade)

    • Medela Pump in Style Advanced with Tote (Upgrade)

    • Medela Sonata (Upgrade)

    • Spectra S2

    • Spectra S1 Rechargeable (Upgrade)

    • Medela Symphony - RENTAL

    • Pumpease Hands Free Pumping Bras

  • PART III- ASK YOUR PHYSICIAN WRITE A PERSCRIPTION FOR A DOUBLE ELECTRIC BREAST PUMP.

    ASSIGNMENT OF INSURANCE BENEFITS AND RELEASE OF INFORMATION:I hereby authorize my public and/or private insurance company or funding resource responsible for paying for my care, if applicable, to pay benefits on my behalf directly Dartmouth Medical Equipment, for any products and services furnished to me by Dartmouth Medical Equipment. I also authorize Dartmouth Medical Equipment, Inc. to request, on my behalf, all public and private insurance benefits for products and services provided to me by Dartmouth Medical Equipment. I hereby authorize Dartmouth Medical Equipment to release my medical records to any person, organization, company and/or agency which is or may be (1) involved in providing care for me or (2) liable for any portion of the payment of the charges for such products and services.

  • Note or Special Instructions: