Outpatient Donor Milk Prescription form

Recipient Child’s Name*

First NameLast Name

Recipient Child's DOB*

Date

Today's Date*

Date

Please provide number* oz/day ml/day* of pasteurized Donor Human Milk for: number* weeks number* months (up to 6).

Medical reason(s) donor human milk is required:*

Diagnosis codes (if more than one, please separate by commas):*

If formula intolerance is a reason for the donor milk request, please list the formulas that have been trialed:

Formula intolerance is defined by the milk bank as continued suboptimal growth and/or symptoms after 3 documented trials of formulas including a hypoallergenic or amino acid based formula.

Is this prescription for discretionary use of donor milk?*

YesNo

Discretionary use describes a situation in which an infant does not have a documented medical indication for human donor milk and has limited or no access to maternal milk. Such use may not be covered by insurance.

Has insurance pre-authorization been requested?*

YesNo

Authorization #:

Plan:

Medicaid and private insurance carriers may cover the cost of donor milk if there is a medical need. Plans require the prescribing physician to contact the insurer to obtain an authorization number. Without insurance authorization, the donor milk processing fee ($30.00/200ml bottle) is the responsibility of the family. You may need the following info when contacting an insurer: Three Rivers dba Mid-Atlantic Mothers’ Milk Bank is a DME provider. The code for human breast milk processing, storage, and distribution is T2101. The milk bank’s NPI# is 1902267594.

Distribution Policy: Medical need describes a diagnosis or circumstance in which donor milk may provide a therapeutic benefit. Such conditions include, but are not limited to, malabsorption disorders, prematurity, short gut syndrome, congenital heart disease, renal disease, post-surgical nutrition, immunological deficiencies, failure to thrive, allergies, and formula intolerance. Mid-Atlantic Mothers’ Milk Bank relies on the generosity of volunteer donors. In times of shortage, priority is given first to NICUs then outpatients with medical needs. Discretionary use orders will only be filled as supply permits. A full explanation of the milk bank’s distribution policy is included in the outpatient packet and online.

Provider Name:*

Practice/Hospital*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number

Fax Number*

Please enter a valid fax number

NPI#:*

Signature*

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Prescription form for pasteurized human donor milk