Request Forms : Pumps & Scales : MilkWorks

Breast Pump Request Form

Thank you for choosing to obtain your breast pump at MilkWorks - your nonprofit community breastfeeding center! We are in-network with all major private insurance plans and Nebraska Medicaid for high quality, double electric breast pumps and our Pump Service Plan is provided with all of our Personal Use Pumps (PUPs). Please fill out the form below to start your breast pump order.

Note: an actual person processes this request and it may take up to 2 business days.

We ALWAYS encourage that you call your insurance provider to verify that a breast pump is a covered benefit under your plan as we cannot guarantee coverage. Please bring your insurance card and a prescription from your healthcare provider. Prescription template can are found here.

First Name

Last Name

Phone

###-###-####

003chxztf79w

Confirm Email

Address

City, State

Zip Code

Date of Birth

Month

Day

Year

Month/Date/Year

Insurance Provider

(i.e. Blue Cross Blue Shield, NE Medicaid, UnitedHealthcare, Aetna, TriCare, etc.)

Baby's Date of Birth or Estimated Due Date

Month

Day

Year

Month/Date/Year

Location Preference for Breast Pump Pick Up

MilkWorks Lincoln (58th & Old Cheney)
MilkWorks Omaha (108th & Center)

Once this request has been submitted and insurance forms are complete, you can pick up your breast pump at either location Monday - Saturday 9am-4pm. If you choose to pick up at a different location than selected on this form, please inform our staff at arrival.

Pickup of Breast Pumps & Supplies:

Please check the box of the location where you would like to pick up your pump. When forms are completed, a staff member will be in touch to send you the appropriate insurance forms and establish the most convenient pickup time.

Need your pump faster? Give us a call at 402.423.6402 in Lincoln or 402.502.0617 in Omaha to have insurance forms emailed to you.