AME Medical Equipment
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Breast Pump Inquiry/Order Form for Medi-Cal Insurance
Some moms have a HMO form of Medi-Cal. At this time,
the only HMOs we can accept are through CalOptima or Gold Coast.
If you have straight/pregnancy Medi-Cal or if it is with CalOptima Care Network, CalOptima Direct, or Gold Coast, please complete the below form.
If you are a member of LA CARE, HEALTH NET, KAISER, CENCAL: We will NOT be able to process your order. Please do not proceed with this order; instead CONTACT YOUR INSURANCE.
Indicates required field
Expected Delivery Date OR Baby's Birth Date
Your Name (which will be the user of the breast pump)
Primary Phone Number
Date of Birth of Mother (the user of the pump)
How did you hear about us?
Insurance ID Number (THIS ID MUST BEGIN WITH A 9)
Have you ever received a breast pump from Medi-Cal IN THE LAST 3 YEARS?
Do you have ANY other medical insurance?
Other Insurance Company AND ID # (if applicable)
AME is here to help with obtaining the prescription from your physician; HOWEVER doctors usually respond to YOU quicker. Although we may assist in obtaining the prescription, we will NOT ship the breast pump to you until we have the prescription. You may ask your doctor for one and send it to us...it just needs to list Breast Pump and a diagnosis.
Name of OB/GYN
OB/GYN Phone Number OR City where office is located
Upload Picture of Prescription (if you have it at this time)
Max file size: 20MB
Submit to See Your Possible Options (STEP 2)
12505 Lambert Road
Whittier, CA 90606
Phn: (562) 698-0266
Fax: (562) 693-0831
Hours of Operation: Mon-Fri: 8:30am - 6:00pm ; Sat: 9:00am - 5:00pm ; Sunday: Closed.