Got a breast pump? We carry insurance-covered accessories for all the major breast pump manufacturers. We'll verify with your insurance to see which accessories, such as extra tubing, breast shields and more, are covered at no cost to you.

First Name

Last Name

Email

Phone Number

Your Date of Birth (Numbers only, YYYYMMDD)

Baby's Due Date/Date of Birth (Numbers only, YYYYMMDD)

Did you order your pump through The Lactation Network? Yes No

If yes, has your insurance or doctor information changed since you placed your order? Yes No Not applicable, my insurance is the same as my last Ashland Breast Pumps order

Insurance Provider

Insurance ID

Group Number

Doctor's Name

Doctor's Phone Number

Shipping Street Address

Address Line Two

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip/Postal Code

Breast Pump Model Ameda Mya Elvie Evenflo (all models) Lansinoh (all models) Medela Freestyle Medela MaxFlow Medela Sonata Medela Symphony Motif Luna Spectra (all models)

Breast Shield Size (in mm) 20 21 24 24.5 25 27 28 30 30.5 32 33

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