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  • Dear Families,  
                                         
    Pasteurized Donor Human Milk (PDHM) offers safe nutrition for infants experiencing medical needs or requiring short-term supplementation when their mother’s milk is unavailable.  At The Milk Bank, our top priority is providing PDHM to premature infants in the NICU. However, thanks to our generous milk donors, we extend access to families on an outpatient basis.

    *Please Note: If milk inventory becomes limited, The Milk Bank follows national triage standards based on medical need, which may temporarily pause outpatient access to PDHM* 
     
    How to Request Outpatient PDHM:

    1. Complete this Outpatient Recipient Form.
    2. Arrange for payment via our secure online platform or by calling 317-536-1670.
      • We are unable to file insurance claims except for Tricare or Indiana Medicaid but we can provide documentation to assist families who wish to claim reimbursement directly.
      • A program offers free or reduced-cost PDHM for eligible families with infants experiencing a medical need whose families face financial barriers. Available to residents of Indiana, Kentucky, and Missouri, this program requires a prescription and additional documentation from healthcare providers. For more information, select the Medical Relief option in the Outpatient Intake Form or contact our Outpatient Specialist. 317-536-1670 | Outpatient@themilkbank.org

    Please note, the approval process typically takes 1-2 business days.
    If your need for milk is critical, please contact us directly

    How to Receive Outpatient PDHM:

    Following approval of outpatient intake form, families may pick up or contact us to arrange direct shipping.  Due to state tissue licensing regulations, we are unable to ship to CA, MD, NY, or PA.

    Milk Express Program (Local Pick-Up)

    • Families can purchase up to 40 ounces (10 bottles) via a secure online platform, then pick up your PDHM order from a Local Pick up Site
    • Families who require larger amounts are encouraged to contact us. This ensures our Milk Express sites can maintain inventory to serve as many families as possible in emergent situations.

    Direct Ship Program

    • PDHM orders can be shipped directly to families Monday–Thursday for next-day delivery if order is received and approved prior to 2:30 PM.
    • Contact 317-536-1670 or Outpatient@themilkbank.org to purchase and schedule delivery.
  • 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.

  • Contact Information

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  • Thank you for your interest in donor milk! State tissue licensing regulations prevent us from shipping milk to California, Maryland, New York, and Pennsylvania. You can find information about milk banks local to your area by clicking here.

    If you are currently visiting another state and wish to pick up milk from one of our Milk Express sites or have our PDHM shipped to you in a state other than those listed above, please input the address of where you are staying or call us at 317-536-1670 to discuss options!

  •   Infant Information

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  •   Second Infant Information

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  •   Third Infant Information

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  •   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 gives our staff permission to contact your infant’s healthcare provider(s) directly, and exchange healthcare information as needed.

  •   Infant's Healthcare Provider's Information

  • I hereby give permission and release The Milk Bank to contact the Health Care Provider(s) identified above to inquire about health information as it pertains to the above infant’s 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 relevant 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 a future period of two years from the date of signature on this form 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.

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  • To arrange & pay for direct shipping, or to discuss our Medical Relief Fund, please contact our Outpatient Specialist at 317-536-1670 or outpatient@themilkbank.org.

  •  Insurance Information

  • If you require an itemized receipt/invoice to submit for insurance/HSA/FSA reimbursement, please contact your insurance provider to find out what information or forms they require for reimbursement approval under your coverage plan. Please email all information to outpatient@themilkbank.org.

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

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  •   Optional Demographics

  • The Milk Bank collects demographic data for reporting purposes and to combat disparities in healthcare.  This information will not influence your ability to access PDHM in any way.

  •   Agreements and Authorizations

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  •   Medical Relief Fund Application

    The Milk Bank offers a Medical Relief Fund (MRF) which offers free or reduced cost PDHM is based on medical need, financial barriers and milk inventory for infants residing in Indiana, Kentucky or Missouri. A qualifying condition does not guarantee approval.   

    Important Note: Additional information from your infant’s healthcare provider is required, which can delay processing and approval. If you have an urgent need for PDHM and require financial assistance, call 317-536-1670 (Option 1) to speak with our Outpatient Specialist.

    While The Milk Bank strives to provide PDHM for all infants in need, we must prioritize our limited supply for the most fragile infants in the NICU. Therefore, approval for MRF is typically to bridge short term infant health needs. Approval beyond 6 months of age may be considered for life-threatening conditions or on a case-by-case basis, depending on milk inventory.

  •   Infant Medical Need Verification

  • To complete your application, a prescription and medical verification from your infant’s healthcare provider are required. We will email you the necessary form upon receipt of your application.  If your need is urgent or if you do not receive the forms, please call 317-536-1670 (Option 1) to speak with our Outpatient Specialist.

  •   Household Information

  •   Financial Information

  • Important Note: Your Medical Relief Fund (MRF) application is incomplete until we receive proof of your family’s financial status. If you cannot provide the documentation now, you may email it later to Outpatient@themilkbank.org.

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  • 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 contact us at 317-536-1670 or outpatient@themilkbank.org.

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