Form F-1153 - Forward Health Breast Pump Order

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

F-01153 (10/2015)

FORWARDHEALTH

BREAST PUMP ORDER

ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible

members.

Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete

claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name,

address, and member identification number [DHS 104.02(4), Wis. Admin. Code].

Under Wis. Stat. § 49.45(4), personally identifiable information about applicants and members is confidential and is used for purposes

directly related to ForwardHealth administration, such as determining eligibility of the applicant or processing provider claims for

reimbursement. Failure to supply the information requested by the form may result in denial of payment for the services.

INSTRUCTIONS

Type or print clearly. This form is to be completed by the physician, given to the provider of the breast pump, and kept in the member’s

medical record as required under DHS 106.02(9), Wis. Admin. Code. The use of this form is voluntary, and providers may develop their

own form as long as it includes all the information on this form.

1. Date of Order

2. Name – Member (Mother)

3. Address – Member

4. Date of Birth – Infant

5. Member ID

6. Clinical Guidelines

All of the following must apply as a condition for coverage. By checking the boxes, the physician verifies that all conditions are met.

Physician ordered or recommended breast milk for infant.

Potential exists for adequate milk production.

Member plans to breastfeed long term.

Member is capable of being trained to use the breast pump.

Current or expected physical separation of mother and infant (e.g., illness, hospitalization, work) would make breastfeeding difficult,

or there is difficulty with “latch on” due to physical, emotional, or developmental problems of the mother or infant.

7. Type of Pump

The physician orders or recommends the following breast pump for use by the member:

Breast pump, manual, any type.

Breast pump, electric (AC and/or DC), any type.

Breast pump, heavy duty, hospital grade, piston operated, pulsatile vacuum suction/release cycles, vacuum regulator, supplies

transformer, electric (AC and/or DC).

8. Name – Physician

9. Address – Physician

10. SIGNATURE – Physician

11. Date Signed

12. Time Signed

Form F-1153 - Forward Health Breast Pump Order - 2015