Infant Recipient Screening Form

Infant Recipient Information:  

Race and Ethnicity of child:
 White or Caucasian
 Hispanic or Latino
 Black or African American
 Asian or Pacific Islander
 Native American or Alaska Native
 Other: 
 I prefer not to answer


For Healthy/Bridge Milk Recipients:
MMBA can serve healthy/bridge milk recipients as supply allows. Families must pay the processing fee for donor human milk services provided at home. Our prices are:

• 1.5 ounce (45ml) bottle: $ 6.98
• 3.0 ounce (90ml) bottle: $13.95

Please let us know in the "Approximate Amount Needed" section the bottle size and volume of milk you prefer and the approximate time you would like to pick up. Keep in mind our team needs at least 2 business hours notice to prepare your order. You may skip the "Formulas Trialed" and "Insurance" Sections.



Recipient Feeding History:

 

 

Physician Information:
 
Payment Information

Insurance coverage is possible only for infants with a medical need for Donor Human Milk. Bridge Milk recipients are self pay only.

 

Agreement for Services

Please initial each of the following sections.

Parental Responsibility

I understand that I am responsible for providing information on any changes in medical status of my baby (child) 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. I understand that I am responsible for providing accurate information on insurance coverage and communication with the insurance company, as well as timely notification of changes in insurance.  I understand that I must provide a copy of the front and back of my insurance card to MMBA with this completed document.

 

Initials 

 

Informed Consent

I understand that donor human milk is prescribed for my baby (child). 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 Mothers' 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 not covered by my health insurance, including the shipping of milk, if applicable. My insurance carrier may provide a prior authorization or pre-certification for services, but that is not a guarantee of payment. MMBA will invoice the balance uncovered by insurance directly to my family. 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 

 

Charitable Assistance

I am aware that the MMBA has a charitable assistance fund to provide milk to families with a medical need when attempts to acquire private or public insurance coverage have failed or the family lacks the financial means to cover the full costs of service. I am aware I must sign an Agreement for Services and complete an Application for Charitable Assistance to be considered. If I am not approved for Charitable Assistance, I am responsible for payment in full. If I am not approved for full coverage of milk processing fees and request a payment plan, I must adhere to the plan.

 

Initials 

 

Assignment of Benefits

I request that payment of authorized insurance benefits be made on my behalf to the agency listed below for services provided to me by that agency. If I am reimbursed directly by my carrier I am responsible for submitting payment for services to the Milk Bank within 7-10 days of receipt and deposit of payment or my services may be terminated. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related services to the agency, my insurance carrier, health care provider or other medical entity. A copy of this authorization will be sent to my insurance company or other entity if requested. The original authorization will be kept on file by the organization.

 

Initials 

 

Communications

I     Do    Do Not  give my permission for MMBA to leave a message with information about donor human milk services at the phone number(s) provided.

I     Do    Do Not  give my permission for MMBA to send information about donor human milk services to the email address(es) 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:
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Relationship to Milk Recipient:

 

 

 

 

 

Release of Medical Information

To:  (name of physician’s office)


I, , parent/guardian of your patient, , authorize your office to release my child’s necessary medical records to Mothers' Milk Bank at Austin, in order for my child to begin receiving banked donor human milk.



Parent or Guardian's Signature
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