Healthcare Lactating Kit

HEALTHCARE LACTATING KIT

Issuance Date:    Kit ID:

Patient Information

Date of Birth:    Gender:

Phone:    Email:    MRN:

Emergency Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Subscriber DOB:

Medical / Lactation Information

Clinician Phone:    Clinician NPI:

Expected or Delivery Date:    Infant Name (if applicable):

Requested Kit Contents

Electric Breast Pump (single or double)    Qty:

Manual Pump    Qty:

Milk Storage Bags    Qty:

Flange Set(s) — sizes:   

Tubing / Adapter Kit    Qty:

Cooler Bag with Ice Pack    Qty:

Battery Pack / Power Adapter    Qty:

Cleaning & Sterilization Supplies (brushes, wipes)    Qty:

Provider Medical Necessity

Provider attests that items requested are medically necessary for lactation support and recovery. Provider Printed Name:

Provider Signature (administrative):    Date:

Patient Acknowledgement & Consent

By signing below I authorize issuance of the lactating kit described above. I acknowledge and agree to the following:

I have received instruction on use, cleaning, storage, and troubleshooting of equipment and supplies and understand the benefits and potential risks of use.

I am responsible for reporting malfunction, damage, or loss. I understand that lost or unreturned loaned equipment may incur replacement or repair charges as described by the issuing facility.

I understand components provided may not be sterile and must be cleaned and sterilized per instructions before use with expressed milk or direct infant contact.

I authorize my healthcare provider and the issuing facility to release necessary clinical and insurance information to process claims and to bill my insurance for items provided. I accept financial responsibility for amounts not covered by insurance.

I understand the return policy for loaned equipment and agree to return loaned items by the due date or upon request by the issuing facility. Return Due Date:

I acknowledge receipt of the facility's privacy notice and authorize disclosure of protected health information related to this kit as necessary for treatment, payment, and facility operations.

Care, Cleaning, and Safety Notices

Follow printed cleaning instructions included with the kit. Do not immerse the electrical components in water. Immediately discontinue use and contact your provider if you experience pain, nipple damage, signs of infection, fever, or any unexpected reaction. Equipment recalled by manufacturer will be reported by the issuing facility when known.

The issuing facility makes reasonable efforts to provide clean and functioning equipment; however, the facility is not liable for complications arising from failure to follow cleaning or usage instructions or from misuse of the kit components.

Sign Now