b"Breast Pump Order FormThis document serves as a Prescription and Statement/Certificateof Medical Necessity for the referenced patient.Patient Name:Date of Birth:Due Date: Insurance Company: Member ID / Insurance ID / Sponsor's SSN or DBN if Tricare: Phone Number: Email: Address: Physician Order: Breast Pump & SuppliesDiagnosis Code:TRICARE/AETNA/AFSPA Beneficiary at 27 weeks or more gestationA birth event before 27 weeks gestation (Age in months: )Legal adoption of an infant who will be breastfed by an eligible TRICARE beneficiary (Age in months:)Other: Breast Pump:E0602 Manual Breast PumpE0603 Double Electric Breast PumpE0604 Hospital Grade (TRICARE Prime Beneficiaries may require a referral)Supplies Needed: TRICARE Beneficiaries eligible for all, AETNA/AFSPA Beneficiaries not qualified.A4282 Standard power adapter: 1 replacement per birth event (not within 12 months of the breast pump purchase date)A4281 Tubing and tubing adapters: 1 set per birth event, 2 units billedA4286 Locking rings: 2 every 12 months, for 36 months, following the birth eventA4285 Bottles: 2 replacement bottles every 12 months, for 36 months, following the birth eventA4283 Bottle caps: 2 every 12 months, for 36 months, following the birth eventA4287 Storage bags: 100 bags every 30 days following the birth event for 36 monthsA9900 Modifier XG Valves/Membranes: 12 units within the first 12 months following the birth event A4284 Breast Shields/Flanges: 1 set, 2 units billed per birth eventA Supplemental Nursing System (SNS) and Nipple Shields are also covered when prescribed and medicallyindicated. If prescribing these, indicate the items below and complete the additional information section formedical necessity. *A9900 Modifier XN Supplemental Nursing System (SNS): 1 per birth eventA9900 Modifier XD Nipple Shields: 2 sets per birth event, 4 units billedLength of Need: Information including the medical necessity for additional supplies: *Tricare coverage may require a referral for the Supplemental Nursing System (SNS). Contact your insurance with any questions.Prescribing Physician InformationPhysician Name: NPI:Physician Address:Phone Number: Fax Number: Physician Signature: Date:www.janzmedicalsupply.com"