Outpatient Intake Form 8.2024

Dear Families, 
                                    
Pasteurized Donor Human Milk (PDHM) provides infants with a safe alternative to formula when experiencing a medical need or for short-term supplementation when mother’s own milk is unavailable. The Milk Bank’s first priority is to serve premature infants hospitalized in the NICU, but thanks to our generous milk donors, we often can extend access to PDHM to families on an outpatient basis.

*In the event milk inventory becomes limited, The Milk Bank follows national triage standards based on medical need and may have to pause providing outpatient access to PDHM.*

How to access outpatient PDHM:
1. Complete this Outpatient Recipient Form.
2. Pay a processing fee of $4.85/ounce via our secure online platform (after submitting this form, you will be taken to a payment page), or call 317-536-1670.
  1. TMB has a Medical Relief Fund available for eligible families - see below.
  2. While TMB cannot currently file insurance claims on your behalf, aside from TriCare or Indiana Medicaid under some circumstances, we can provide the necessary documentation for you to request reimbursement.
3. Make arrangements to pick up your order at a Milk Express location near you or contact us at 317-536-1670/Outpatient@themilkbank.org to schedule delivery. See below for more details!
Milk Express Program (Local Pick-Up) - Up to 40 oz per purchase
Families can purchase up to 40 ounces per transaction, per day from a convenient Milk Express (MX) site. Families who require larger amounts are encouraged to contact us. This ensures our MX sites can maintain inventory to serve as many families as possible in emergent situations.

Direct Ship Program
PDHM can be shipped directly* to families Monday-Thursday, to arrive the next day. Friday shipping may be available based on ability of family to receive delivery and pay Saturday delivery surcharge.

Please note: any requests made after 2:30 pm will be handled the next business day.
We currently cannot ship to the following states due to state tissue licensing regulations and other restrictions: CA, MD, NY, and PA.

*Additional shipping and handling rates apply.

Medical Relief Fund
The Milk Bank’s Medical Relief Fund provides free or reduced rates for PDHM and is reserved for infants with a critical medical need for PDHM whose families are facing financial hardship. This program is limited to families residing in Indiana, Kentucky, and Missouri. Additional documentation from the family and the infant’s healthcare provider is required for approval. Please contact our Outpatient Specialist for more information or if you have an urgent need for donor milk and cannot afford it.

Please Note: You do not have to complete the entire form at once. If you click the "Save My Progress" button at the bottom of any page, a link to your application will be emailed to you so you can complete it later.

THE INFANT'S PARENT OR LEGAL GUARDIAN MUST BE THE ONE TO COMPLETE AND SIGN THIS FORM!
Contact Information
Name of Parent/Guardian 1*

First NameLast Name
Name of Parent/Guardian 2

First NameLast Name
Is the person completing this form one of the above Parents/Guardians?*

YesNo
Name of Person Completing the Form*

First NameLast Name
First Name of Parent/Guardian*
Last Name of Parent/Guardian*
Relationship to Baby*
Parent/Guardian Phone Number*
Parent/Guardian Email Address*
example@example.com
Parent/Guardian Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you interested in free lactation support services, in-person or virtually?*

YesNo
Would you like an interpreter?*

YesNo
What language?
Please select which Milk Express location you will pick up your order from, or if you need to speak with us about direct shipping or our Medical Relief Fund (MRF):*
NOTE: Current pick up locations can be found here!

Infant Information
Infant's Name*

First NameMiddle NameLast Name
Infant's Birthdate*

MonthDayYear
Date
Sex
Gestational Age at Birth*
How many weeks pregnant was mom at birth?
Birth Weight*
Current Weight*
Is the infant currently hospitalized?*

YesNo
If yes, why?
What symptoms/concerns is the infant experiencing?*
How is the infant currently being fed? Please include details about breastfeeding, pumping, frequency, formula feeding, etc.*
If the infant receives formula, please list what kind(s) have been used & describe any health concerns after receiving formula: *
Please provide details on your infant’s feeding goals and any support received from a lactation consultant or other healthcare professional: *
Approximate daily/weekly amount of donor milk required (Donor milk comes in 4oz bottles):*
Are you requesting PDHM for a second infant at this time?*

YesNo

Second Infant Information
Infant's Name*

First NameMiddle NameLast Name
Infant's Birthdate*

MonthDayYear
Date
Sex
Gestational Age at Birth*
How many weeks pregnant was mom at birth?
Birth Weight*
Current Weight*
Is the infant currently hospitalized?*

YesNo
If yes, why?
What symptoms/concerns is the infant experiencing?*
How is the infant currently being fed? Please include details about breastfeeding, pumping, frequency, formula feeding, etc.*
If the infant receives formula, please list what kind(s) have been used & describe any health concerns after receiving formula: *
Please provide details on your infant’s feeding goals and any support received from a lactation consultant or other healthcare professional: *
Approximate daily/weekly amount of donor milk required (Donor milk comes in 4oz bottles):*
Are you requesting PDHM for a third infant at this time?*

YesNo

Third Infant Information
Infant's Name*

First NameMiddle NameLast Name
Infant's Birthdate*

MonthDayYear
Date
Sex
Gestational Age at Birth*
How many weeks pregnant was mom at birth?
Birth Weight*
Current Weight*
Is the infant currently hospitalized?*

YesNo
If yes, why?
What symptoms/concerns is the infant experiencing?*
How is the infant currently being fed? Please include details about breastfeeding, pumping, frequency, formula feeding, etc.*
If the infant receives formula, please list what kind(s) have been used & describe any health concerns after receiving formula: *
Please provide details on your infant’s feeding goals and any support received from a lactation consultant or other healthcare professional: *
Approximate daily/weekly amount of donor milk required (Donor milk comes in 4oz bottles):*

Infant's Healthcare Provider's Information
Infant's Healthcare Provider's Name (Pediatrician/Family Physician, etc.)*
Provider Phone*
Provider Fax
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization for Release of Information
The Milk Bank recognizes the importance of patient confidentiality as part of our relationship with you. In an effort to serve you and your family while ensuring The Milk Bank maintains responsibility for adequate milk inventory levels, it may be necessary to collect additional information or discuss patient healthcare information with your baby’s healthcare provider. Completing this authorization allows our staff to contact your infant’s healthcare provider directly if needed. Please read the statement below and add your signature to grant us such permissions:

I hereby give permission and release The Milk Bank to contact the Health Care Provider identified above to inquire about health information as it pertains to the above infant’s/infants' participation in The Milk Bank’s outpatient program. This may include, but is not limited to, information about infant growth, feeding, medical diagnosis, test results, treatment, health history, and full medical records. I further request and authorize the above-named healthcare provider to provide such information to The Milk Bank. I further release The Milk Bank to provide information to my healthcare provider regarding my outpatient request for pasteurized donor human milk, including but not limited to infant growth, feeding, medical diagnosis, test results, treatment, health history, and payment history. This authorization is valid to share health information for all past, present, and future periods unless revoked to The Milk Bank in writing. In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. I understand that failure to submit this authorization or revocation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits.
Responsible Party Signature*

Clear
Date*

MonthDayYear
Date

MRF Eligibility & Insurance Information
Does your baby have a medical need for PDHM AND you have a financial need limiting your ability to pay for it (including if baby has Indiana Medicaid) AND you live in IN, KY, or MO?*

Yes, I meet all 3 criteriaNo
Please complete the "Medical Relief Fund Application" on the following pages, so we can determine if your family is eligible for free or reduced-cost PDHM!
Baby's Primary Insurance Provider*
Baby's Secondary Insurance Provider
Do you need an itemized receipt/invoice to submit for insurance/HSA/FSA reimbursement?

YesNo
Please contact your insurance provider to find out exactly what information or forms they require for reimbursement to be approved under your coverage plan. Once you have that information, please email it to Outpatient@themilkbank.org.

Note: Our accounting processes operate similar to medical billing, so we may not be able to provide a requested receipt/invoice for up to 4-5 weeks after your purchase date(s).

Household Information
Please list ALL household members who live with the baby, including baby, all adults and all children. Click "Add Row" to add more members as needed.*

If you would like to review/edit the information you have provided, you can do so by clicking the "Back" button below. Otherwise, click the "Submit" button.

If you are paying online to pick up PDHM at a Milk Express, you will be automatically redirected to the payment page - you may need to enable pop-ups to see it!

If you are requesting direct shipping or applying for MRF, our staff will reach out to you within 1 business day, or you can call 317-536-1670.
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