MOTIF REQUEST FORM Mom's Full Name *Email Address *Phone Number *Mom's Birth Date *Month *Day *Year *Baby's Due Date *Select your Insurance *AmerigroupParklandMolinaAetna Better HealthSuperiorCook Children'sRightCare-Scott and WhiteFirstcareTexas MedicaidTexas Children'sCHIPCommercial InsuranceInsurance ID Number *OBGYN Clinic's Information *Clinic's NameCityClinic's Phone NumberDoctor's NameI WOULD LIKE: ( ALL ITEMS ARE AT NO COST WITH MEDICAID )BREAST PUMPBLOOD PRESSURE MONITORSUPPORT BAND ( During Pregnancy )Benefits of Support Bands:• Helps to disperse the weight of your growing baby • Increases stability • Alleviates pain • Decreases SI joint pain • Lowers round ligament pain • Reduces pressure on the bladder • Supports prenatal activities or exercises • Corrects posture • Reduces sciaticaSupport Band SizeXS ( Pre-Pregnancy Pant Size: 2 )S ( Pre-Pregnancy Pant Size: 4 )M ( Pre-Pregnancy Pant Size: 6 - 12 )L ( Pre-Pregnancy Pant Size: 14 - 20 )XL ( Pre-Pregnancy Pant Size: Over 20 )Only available during pregnancy*COMPRESSION SOCKSBenefits of Compression Socks:• Prevents swelling • Reduces discomfort • Increases blood circulation • Prevents or minimizes risk of varicose and spider veins • Helps prevent blood clots • Lowers your risk of deep vein thrombosis (DVT) • Assists with long days on your feet • Increases overall comfort throughout the dayCompression Socks SizeS (Ankle: 6.5" - 8.5" / Calf: 11" - 16.5 ")M (Ankle: 8" - 10" / Calf: 12" - 17.5 ")L (Ankle: 9" - 11.5" / Calf: 13" - 19 ")XL (Ankle: 11" - 15" / Calf: 17" - 23 ")POSTPARTUM RECOVERY SUPPORT GARMENTBenefits of Postpartum Recovery Support Garment:• Provides gentle compression & support to reduce swelling, soreness, and pain • Stabilizes the abdomen, lower back, and hips for improved posture • Increases overall mobility • Tightens and tones belly, hips, waist, pelvis, and lower backPostpartum Recovery Support Garment SizeS ( Pre-Pregnancy Pant Size: 0 - 4 )M ( Pre-Pregnancy Pant Size: 6 - 8 )L ( Pre-Pregnancy Pant Size: 10 - 12 )XL ( Pre-Pregnancy Pant Size: 14 - 16 )2XL ( Pre-Pregnancy Pant Size: 18 - 20 )Language PreferenceEnglishSpanishPlease provide a good mailing address for delivery of products:Street Address *Apartment, suite, etcCity *State *ZIP / Postal Code *I understand that Medicaid will pay for one electric breast pump. Any other electric breast pumps I received will be an out-of-pocket expense.**I acknowledge.By checking this box, you consent to receive SMS updates regarding your order. Message and data rates may apply. To opt-out at any time reply ‘STOP’ to any of our messages.I consent.Please expect a text from RSQ Medical Equipment within 24 hours regarding your request. To opt out of texting, please indicate other preferred method of contact:SUBMIT APPLICATION Like us on Facebook!
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