Adult Recipient Screening Form

Where did you hear about  us?
 Health Care provider referral
 Hospital referral: 
 MMBA Brochure
 Google or other search engine
 Other:  

Race and Ethnicity:





: 

Recipient Contact Information:

 
First Name
Last Name
Gender:
  
Birth Date:
Cell Phone
Alternate Phone 
Email
Address
Address
City
State
Zip 
Diagnosis:
Diagnostic Code:
Symptoms/Concerns:
Hospitalized?
   
 
 
Has the use of donor milk been discussed with the recipient's Physician?
 ​ 
Approximate amount needed:
 
 
 

Secondary Contact Info: 

 
First Name
Last Name
Cell Phone
Alternate Phone
Email
Address
Address
City
State
Zip
Relationship to recipient
 
 
 
 

 

Physician Information:

First Name
 
Last Name 
 
Specialty
 
Phone
 
Fax 
 
Address   
 
Address 
 
City
 
State 
 
Zip 
 
Physician will fax prescription?
   
Upload Script
 
 
 
 
 
 
 

Payment Information:

Discussed Cost?
 
Self Pay? 
 

 

Agreement for Services

Please initial each of the following sections.

Patient Responsibility

I understand that I am responsible for providing information on any changes in my medical status including, but not limited to introduction of other foods, changes in milk volume consumed per day, hospitalization, and surgery. I agree to call the milk bank each week with an indication of amount of milk needed to be sent or picked up, and I will obtain updated prescriptions as warranted by either expiration dates or changes in volume.

 

Initials 

 

Informed Consent

I understand that donor human milk has been prescribed by my physician. I have received verbal and written information from the staff of the Mothers’ Milk Bank at Austin (MMBA) on the screening, pasteurization, storage, and handling procedures for donor human milk. I understand that there are no known risks to the use of pasteurized donor human milk. I acknowledge that I have received a copy of the organization’s Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.

Initials 

 

Financial Responsibility

The Mother’s Milk Bank at Austin (MMBA) is a non-profit organization providing donor human milk to premature and otherwise fragile infants, as well as other individuals’ with a medical need.  It is the desire of MMBA to provide donor human milk in a manner protective of the financial solvency and sustainability of the organization.

I understand that I am financially responsible to the MMBA for the processing fees, including the shipping of milk, if applicable. Donor human milk use by adults in considered experimental and is not covered by insurance.  MMBA will invoice my family directly.  I understand it is my responsibility to pay my bill in full or maintain regular contact regarding payments. I understand that by signing this form I am accepting financial responsibility, as explained above, for all payments for services received.

Initials 

Communications

I       give my permission for the MMBA staff to leave a message on my home answering machine or with a family member at my home number.

I       give my permission for the MMBA staff to contact me using the email address provided.

AGENCY

Mothers' Milk Bank at Austin
5925 Dillard Circle
Austin, Texas 78752
877-813-6455


Name of Financially Responsible Party:

 

Signature of Financially Responsible Party:
Use your mouse or finger to sign in the box below.



 

Release of Medical Information



To:  (name of physician’s office)


I, , authorize your office to release my necessary medical records to Mothers' Milk Bank at Austin, in order for me to begin receiving banked donor human milk.



Recipient's Signature: 
Use your mouse or finger to sign in the box below.

Reset Signature

 

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