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 fieldMember's name (mother)*Newborn's birthdate*Please complete the form after the baby is born. Date Format: MM slash DD slash YYYY Member's Medicaid ID (mother)*Place of Birth (e.g. hospital name, home)*Member's residential address*City, State*ZIP code*Section II Requirements: Medicaid Enrolled member must provide date of birth and prescription for the double-electric breast pump. Attestation: 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.Signature*Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.