Maternity Prescription Form — General Home Medical Supply, Inc.

Thanks to the Affordable Care Act (also known as ObamaCare), health insurance plans are required to support breastfeeding, so nearly all insurance providers cover Breast Pumps and Maternity Medical Supplies. As a valued patient, you're eligible for additional benefits, including hospital-grade Breast Pumps and top quality Maternity Medical Supplies.

If you have questions about insurance approval, the supplies offered, or our process, please reach out to us at Phone: 888-311-0666 or alternatively via Email: INFO@GHMSRX.COM

Patient Information

Name *

Phone *

Address *

City

State

Zip

Date of Birth

Age

Height

Weight

Due Date

Insurance Information

Medi-Cal HMO PPO

Primary Insurance

Secondary Insurance

ID #

Group #

Phone

Date Card Issued

Medical Condition & Diagnosis: ICD-10 Information

Other

Maternity & Postpartum Supplies CHECK ITEM · INITIAL · QTY

Breast Pumps CHECK ONE PUMP – This breast pump prescription also includes breast pump resupply kits and up to 300 breast milk storage bags per month, based on patient need and insurance coverage.

Prescriber's Information

I have reviewed my patient's medical records and prescribed the above supplies. I verify that I have physically examined the patient and established that the patient has the medical condition and diagnosis indicated. I have determined that these products are medically necessary for my patient's current medical condition. I authorize the prescribed items and will maintain a copy of this prescription in the patient medical records to meet Medi-Cal documentation requirements.

Prescriber' Name *

Address *

City State Zip

Phone * Fax

NPI

License

Rep

Contact Name

Prescriber' Signature

Sign with a finger, stylus, or mouse

Date

FAX PRESCRIPTION & MEDICAL RECORDS TO 888-611-0666 717 Lakefield Road, Suite D, Westlake Village, CA 91361 | Phone: 888-311-0666 | Fax: 888-611-0666 | ghmsrx.com