PATIENT INFORMATION SHEET
Thank you very much for your interest in purchasing Pasteurized Donor Human Milk (PDHM). The following provides information on our outpatient donor milk program. We realize that human milk is the ideal food for infants and would like to be able to provide PDHM to all that request it from The Milk Bank. When supplies allow, PDHM may be obtained outside of the hospital setting for many reasons. We have tried to make purchasing milk as easy for you as possible. Please read all the information carefully and do not hesitate to contact us with any questions.
Our PDHM is a scarce resource and in limited supply, therefore we must follow a priority system in deciding who can receive our milk. The priorities are as follows:
Hospitalized and ill premature infants.
Well, at home premature infants.
Infants less than 12 months old with medical conditions likely to respond to PDHM.
Individuals more than 12 months old with medical conditions likely to respond to PDHM therapy.
Individuals more than 12 months old with chronic medical conditions.
Infants for short-term use, no specific medical condition.
Laboratory research (milk that cannot be used for human consumption).
Outpatient Intake Forms must be completed and sent to The Milk Bank. The buttons below allow you to complete the application form online or, if you prefer, you can download, print and email the application to firstname.lastname@example.org or fax the application to 317-536-1676.
Outpatients may initially receive up to 40 ounces of PDHM. If outpatients require any additional milk, a Physician’s Prescription is required and must be faxed to The Milk Bank at 317-536-1676, or emailed to email@example.com This prescription should include the recipient’s diagnosis, the amount of PDHM that is being prescribed, and the length of time for which the PDHM is being prescribed. For infants under one year, the prescription must be renewed every three months. For recipients over one year, the prescription must be renewed every six months.
A Letter of Medical Necessity may be required from the physician if the recipient requires long term provision of PDHM or does meet our criteria for patient prioritization.
The Milk Bank office hours are: Monday-Thursday, 8:00am – 4.30pm and Friday 8:00am – 2pm. To allow time for processing, we request that all outpatient orders are received by 3:00pm Monday -Thursday and by 12:00pm on Fridays. Please note that any out of hours inquires will be handled the next business day.
Additional documents you should be aware of are available below, please take a moment to review them and retain them for later referral:
While we strive to provide milk for as long as is medically indicated, we continually review our outpatient need on a case by case basis. We will evaluate your specific situation based on the information provided.
Outpatient PDHM from The Milk Bank is dispensed frozen in 4- ounce and 8-ounce bottles. This milk may be from donor mothers who have delivered a baby within the last 24 months. All our milk donors are rigorously screened and tested. Milk from an approved donor is randomly pooled, to ensure a varied mix of nutrients, pasteurized and tested, before being dispensed.
While The Milk Bank is a nonprofit organization, the costs to procure and process PDHM are very high. We therefore charge a processing fee of $4.50 per ounce to help defray those costs. This processing fee does not cover all the costs incurred by The Milk Bank in the processing of the milk. We accept checks or credit cards for payment. Insurance companies may reimburse for the milk; however, this is usually on a case-by-case basis. We do not bill insurance companies, and payment is expected when the milk is received. We will help you work with your insurance company if you choose to submit the invoices for payment. If you are unable to pay the processing fee, please contact us to discuss any financial concerns.
Again, thank you for your interest in outpatient pasteurized donor human milk. We look forward to working with you.
Sarah Long, IBCLC
Director of Clinical Operations