Outpatient Intake Form 04.2025

Contact Information
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Parent/Guardian 1

First NameLast Name
Name of Parent/Guardian 2

First NameLast Name
If you are not the parent/legal guardian, provide name and relationship to infant:
Parent/Guardian Phone Number
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Parent/Guardian Address

Street Address

Street Address Line 2

CityState

Zip Code
Thank you for your interest in donor milk! State tissue licensing regulations prevent us from shipping milk to California, Maryland, New Jersey, 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!
Thank you for inquiring about safe donor milk for your infant!

At this time, we do not typically serve outpatients in your area, but there is likely another HMBANA accredited milk bank closer to you! Local milk banks can often supply you with pasteurized donor human milk quickly and with lower shipping complications and costs.

If you have an urgent need after you have connected with your local milk bank, please contact us directly at outpatient@themilkbank.org or by calling 317-536-1670.
Are you interested in free lactation support services, in-person or virtually?
Would you like an interpreter?
What language?
To arrange & pay for direct shipping, or to discuss our Medical Relief Fund, after completing this form please contact our Outpatient Specialist at 317-536-1670 or outpatient@themilkbank.org.

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have additional healthcare providers?
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.
Responsible Party Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Insurance Reimbursement FYI
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).

Medical Relief Fund Application

The Milk Bank offers a Medical Relief Fund (MRF) which offers free or reduced cost PDHM for infants residing in Indiana, Kentucky or Missouri based on:
- medical need (verified by a physician),
- financial barriers (family income of 130-185% of federal poverty line),
- and milk inventory.
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.
Are you interested in applying for the Medical Relief Fund?

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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