• Electronic Breast Pump Request Form

    Completed form must be submitted to DXC Technologies along with your breast pump claim for retrospective review.

  • Section I:

    Please print all recipient information below.
    *Denotes required field

  • Date Format: MM slash DD slash YYYY
  • Section II

    Requirements: Medicaid Enrolled member must provide date of birth and prescription for the double-electric breast pump.


    By signing this form, I attest that I have not received a breast pump from WIC for the delivery listed above. I understand that getting a breast pump from both WIC and Medicaid would be a duplication of services.

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.