Checklist for Ordering Banked Donor Human Milk

The following items must be faxed or mailed to the Mothers’ Milk Bank of North Texas prior to providing donor human milk for your client.

______1.    Signed and dated prescription that includes the following:
1)    Diagnosis

2)    Estimated amount in ounces or ml to be dispensed per day or per week

3)    Time frame of prescription (Medicaid prescriptions are to be renewed every 180 days).

______2.    A signed and dated information consent form indicating that the benefits and risks of using banked donor human milk have been discussed with your patient’s parent/guardian.  (Included in packet).

______3.    Pertinent medical history, lab values and test results that support the diagnosis and indicate the patient’s clinical course.  Records should document what artificial breast milk substitutes have been tried and the results of those feeding trials.  (Clinical feeding trials should occur every 180 days and/or in the 10th month of life in order to begin the process of weaning the baby to other sources of nutrition as tolerated.)

______4.    MEDICAID PATIENTS ONLY: Physician should complete, sign and date form.  Note that the Dates of Service are for 180 days.  One copy should be kept on your office chart and a copy faxed or mailed to MMBNT.