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
Clear selection
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)
Insurance Group Number *
Mother's Name (Include Middle Initial) *
Mother's Insurance ID Number *
Mother's Date of Birth *
MM
/
DD
/
YYYY
Infant's Name (Include Middle Initial) *
Infant's Insurance ID Number (If Available)
Infant's Date of Birth *
MM
/
DD
/
YYYY
Policy Holder Name (Self/Spouse/Parent, Include Middle Initial)
Policy Holder Insurance ID (If Different Than Mother)
Policy Holder Date of Birth
MM
/
DD
/
YYYY
Street Address *
City *
State *
Zip Code *
Phone number *
Additional Information for PLS
Thank You and God Bless
Brenda, Jennifer, Rachel, Laura
Premier Lactation Services
703-822-1690
Brenda, Jennifer, Rachel, Laura
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy