This one-page request serves as a letter of medical necessity so a breastfeeding mother can get an appropriate pump through Louisiana WIC. The clinician records mother and baby details, insurance and pump coverage, the pump type and the reasons, from a NICU stay over 72 hours to low milk supply or a return to work, and sets how long a loaned pump is needed.
An MD, NP, PA, IBCLC or RN completes the mother's and baby's details, the pump type and the reasons for need, then signs the authorization.
Download the current version from the source each time; forms change without notice.
Medical Necessity Breast Pump Referral
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The form lists a baby in the NICU expected to stay more than 72 hours, latch problems, inadequate milk production, poor infant weight gain, jaundice, tongue tie, mastitis, engorgement, inverted or cracked nipples, cleft palate, multiple births, a preterm infant, oversupply, thrush, plugged ducts, and a mother returning to work or school.
Yes. The authorization line accepts a signature from an MD, NP, PA, IBCLC or RN. Louisiana WIC also posts a Breast Pump Guide for Medical Providers next to the fillable request on its medical provider resources page.