Aetna Insurance Registration Form
Please complete the form prior to consultation. Mother & Infant insurance must be verified prior to consult.

**NOTE** We are only able to accept Aetna Members ID numbers that begin with "W" at this time (Example: W123456789)

Aetna allows for 6 consults free of cost sharing (no copays / no coinsurance.) Appointments are treated as a newborn well check, except breastfeeding. Consults can include a prenatal breastfeeding class, home visits with infant weigh-ins, teach different hold techniques & other breastfeeding education for 6 weeks. We will reassure you when nursing is going well or notify you if anything needs changed before your milk supply is impacted. Let us know if you would like to setup a 6 week appointment contract to guide you through your nursing journey.

Schedule Recommendation:
Week 1 Private, Prenatal Breastfeeding Class
Week 2 Lactation Consult: Engorgement & Oral/Suck/Nursing Eval, 24 - 48 hrs After Arrival Home
Week 3 Lactation Consult: First Growth Spurt/Milk Transfer
Week 4 Lactation Consult: Review Nursing Positions/Milk Production Assessment
Week 5 Lactation Consult: Review Introduction to Bottle & Pumping
Week 6 Lactation Consult: Over-Active Let Down & Reflux Evaluation

Email address *
I would like to contract PLS for 6 weeks of Lactation Consults
Insurance Plan Type *
HMO's may require an OB and Pediatrician referral prior to a consult. Contact Aetna to determine if a referral is needed for reimbursement. PLS can also determine pre-certification requirements.
Insurance Plan Name
If known, include your plan name. (Aetna Select; Aetna Choice POS II, HMO Open Access, Etc)
Your answer
Insurance Group Number *
Your answer
Mother's Name (Include Middle Initial) *
Your answer
Mother's Insurance ID Number *
Your answer
Mother's Date of Birth *
MM
/
DD
/
YYYY
Infant's Name (Include Middle Initial) *
Your answer
Infant's Insurance ID Number (If Available)
Your answer
Infant's Date of Birth *
MM
/
DD
/
YYYY
Policy Holder Name (Self/Spouse/Parent, Include Middle Initial)
Your answer
Policy Holder Insurance ID (If Different Than Mother)
Your answer
Policy Holder Date of Birth
MM
/
DD
/
YYYY
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone number *
Your answer
Additional Information for PLS
Your answer
Thank You and God Bless
Laura, Jennifer, Rachel, Sharon
Premier Lactation Services
703-822-1690
Laura, Jennifer, Rachel, Sharon
A copy of your responses will be emailed to the address you provided.
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