Recipient Information and Application Packet 06.2022

CONTACT INFORMATION
Date*

MonthDayYear
Date
First Name of Parent/Guardian*
Last Name of Parent/Guardian*
Relationship to Baby*
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INFANT INFORMATION
Baby's Name*

First NameLast Name
Baby's Birthdate*

MonthDayYear
Date
Gender
Birth Weight*
Current Weight*
Was the infant premature?*

YesNo
If yes, how many weeks gestation at birth?
Is the infant currently hospitalized?*

YesNo
If yes, why?
Are you requiring pasteurized donor human milk to feed your infant during the formula shortage crisis? ?

YesNo
What symptoms/concerns is the infant experiencing?*
How is the infant currently being fed? (Please include any information about breastfeeding, formula feeding, etc.)*
What, if any, are your breastfeeding goals? The Milk Bank can refer or provide free lactation consultation.*
INFANT PHYSICIAN AND HEALTH INFORMATION
Physician Name*
Practice Name
Physician Phone*
Physician Fax
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please attach a prescription for pasteurized donor human milk (PDHM) or note if your infant's physician will fax or send prescription electronically.
Upload prescription here if applicable.

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What is the approximate amount of donor milk needed to support or supplement your infant (if known)?
OPTIONAL DEMOGRAPHICS
The Milk Bank collects demographic data for reporting purposes and to combat disparities in healthcare. This information will not influence your application in any way.
Infant / Recipient's ethnicity is identified as (select all that apply):

Asian or Pacific IslanderHispanic/LatinXBlack/African or African AmericanIndigenous, Native American, or Alaska NativeWhite or CaucasianPrefer not to answerMy race and ethnicity is not listedOther
Infant / Recipient's gender is identified as:

FemaleMaleNonbinaryPrefer not to sayMy identity is not listedOther
Do you identify as having a disability?

YesNoPrefer not to say
The primary language spoken in my household is:

EnglishSpanishMandarinArabicMy primary language is not listedOther
What is the level of your annual household income?

Less than $25,000$25,000 - $50,000$50,000 - $100,000$100,000 - $200,000More than $200,000I prefer not to sayOther
I identify as a single parent:

YesNo
How did you hear about us?

Social MediaHealth Care ProviderHospitalSupport GroupFriendInternet SearchOther
AGREEMENTS AND AUTHORIZATIONS*

I have read information included in the outpatient information packet including, but not limited to, the welcome, storage and use of PDHM, and HIPAA information.I understand all milk provided by The Milk Bank,regardless of fee, is for exclusive use of the intended recipient. I will not share, give or sell milk receivedfrom The Milk Bank. I understand thatproviding milk to a third party will result in retroactive assessment of fullfees, financial penalties associated with the sharing/sale, and likely loss ofaccess to future milk.I agree to notify The Milk Bank to any changes in medical need or other situations that impact the amount or duration of milk needed.I understand that The Milk Bank makes no guarantee regarding the availability of pasteurized donor human milk. Further, The Milk Bank provides pasteurized donor human milk based on triage of medical need.I understand that I am financially responsiblefor the processing fees at the rate of $4.85/ounce. Subject to written request and approval formedical relief, fess may be waived or assessed on a sliding scale.I attest the information contained in this application is true and correct and subject to verification by The Milk Bank. I understand that if the information I submit is now or at any time in the future determined to be false, such a determination will result in current and/or retroactive denial of services and additional fees.
If you are picking up your PDHM please identify which site you will visit:*
FINANCIAL INFORMATION
Primary Insurance Provider
Secondary Insurance Provider
The Milk Bank does not currently bill insurance directly; however, your insurance provider may reimburse you for your donor milk on a case-by-case basis. TMB can provide supporting documentation to help you seek reimbursement.
I have financial need limiting my ability to access donor milk. I’d like additional information regarding the medical relief fund.*

YesNo
What is your annual household income?
Net:
Gross:

Are you participating in any of the following programs (check all that apply)?*

Supplemental Nutrition Assistance Program (SNAP)Women, Infants, and Children (WIC) ProgramMedicaid or State-Sponsored InsuranceSubsidized HousingFree or Reduced Lunch (FRL) ProgramOther Public Assistance
Upload proof of participation in at least one of the above programs.*

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Do you have expenses such as medical bills that limit your ability to access pasteurized donor human milk for your baby?*

YesNo
I am (check all that apply)

Unable to pay for PDHMAble to partially pay for PDHM on a sliding fee scaleAble to make a one time payment for PDHMOther
AGREEMENTS AND AUTHORIZATIONS*

I understand that The Milk Bank depends on generous donations of both milk and money. Due to inventory, supply and demand, and operational realities, The Milk Bank makes no guarantee regarding the availability of pasteurized donor human milk regardless of ability to pay.I understand that The Milk Bank provides pasteurized donor human milk based on triage of medical need. Additionally, The Milk Bank uses objective and subjective assessments of ability to pay and extenuating circumstances.I understand that the outpatient family or designee is financially responsible for processing fees. Subject to approval of this applications, fees may be assessed on a sliding scale.I understand that the information submitted is subject to verification by The Milk Bank. I further understand I may be requested to submit ongoing eligibility verification at a later date.I agree to notify The Milk Bank to any changes in medical need, financial circumstances or other situations that impact the amount or duration of milk needed.I understand all milk provided by The Milk Bank, regardless of fee, is for exclusive use of the intended recipient. I will not share, give or sell milk received from The Milk Bank. I understand that providing milk to a third party will result in retroactive assessment of full fees, financial penalties associated with the sharing/sale, and likely loss of access to future milk.I attest the information contained in this application is true and correct. I understand that if the information I submit is now or at any time in the future determined to be false, such a determination will result in current and/or retroactive denial of Drops of Love and I will be liable for charges for services rendered.I agree to submit additional information such as paystubs, tax returns or similar proofs of income as requested to aid in determining eligibility.
Responsible Party Name

{firstName} {lastName}
Date

{date84}
Signature*

Clear
Should be Empty:

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