Request Breast Pump Forms : Calendar & Patient Portal : 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). To begin the process online, please fill out the request below.

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

You have the option of completing the forms ahead of time or when you come to pick up your pump. There is no appointment necessary and breast pumps are available for same day pick up. If you have ANY questions, don't hesitate to call us at 402.502.0617 (Omaha) or 402.423.6402 (Lincoln).

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. Many insurers require that a patient be 36 weeks pregnant before obtaining her pump. Please bring your insurance card and a prescription from your healthcare provider. Prescription template can are found here.

First Name

Last Name

Phone

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

bospxd2ecl15

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.