Insurance

Name of Lactating/ or Pregnant Parent *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Baby’s First and Last name (Put pregnant if baby not born) *

First Name

Last Name

Date of Birth or Estimated Due Date *

MM

DD

YYYY

Type of visit: Click all that you are interested in *

Home (with in 30 to 40 min. from Quince Orchard High School)

Office (LCA clients - can be seen at Regus offices which are located throughout the area)

Others can be seen at Enclave Co-working Space in the Kentlands on evenings and weekends)

Virtual

Breastfeeding Support Group In Person

Breastfeeding Support Groups Virtually

Breastfeeding Group Class In Person

Breastfeeding Group Class Virtually

How soon do you want to be seen?If you have breast or nipple pain or are concerned about baby’s weight gain then please pick emergent below

Emergent (within 36 hours)

Urgent (within 72 hours)

Not Urgent (within a week)

Planning ahead (with in a month or more)

*

Tricare West & Tricare East All Tricare Prime or Tricare Select plans (includes Reserve, Retiree, Young Adult, etc.) NOTE: Must be at least 27 weeks pregnant Please note the pay out for Tricare is very low and only so many codes get approved. Once 6 codes of service have been used there is cost sharing of 110 dollars per visit. All Tricare home visits have a travel fee that will be listed at the end of the form. In addition Tricare only accepts billing for the lactating parent. However there is no preapproval needed. The following insurances may be covered with some or no cost sharing. Please note that the appointment must be booked in 24 hours in advance, To allow time for insurance to be checked. (Require pre approval) Please click the insurance you have below

NA

Aetna/Meritain Select (local plans only)

Aetna/Meritan Subsidiaries

Blue Cross Blue Shield PPO

Blue Cross Blue Shield EPO

CHAMPVA

Oscar - LOA required

CIGNA HMO - requires referral

UHC/UMR/GEHA/Empire/Oxford Doctor’s Plan

UHC/UMR/GEHA/Empire/Oxford Navigator

UHC/UMR/GEHA/Empire/Oxford Core

UHC/UMR/GEHA/Empire/Oxford Nexus

Sliding Scale *

Only fill out if you are unable to be seen with insurance coverage and cannot afford my full self pay rates. check all that apply

I am on WIC/ Medicaid/ Medicare/ Food Stamps

I do not have insurance

I am with in 20878 or with in 20 minutes of Quince Orchard High School

My household income is less than 400 percent of the federal poverty level

I am/ My partner is a federal government employee or contractor former/ current that is unable to self pay

I am/ My partner is a federal government employee or contractor former/ current that is uncertain of insurance coverage due to current circumstances

Please invite me to any free groups or classes virtual

Please invite me to any free groups or classes in person