Ordering Milk for an Outpatient

Ordering Milk for an Outpatient

The Mothers’ Milk Bank of North Texas dispenses milk to outpatient infants by prescription only.  Milk is prioritized to hospitalized infants first and then to infants at home with a medical need. The Mothers’ Milk Bank of North Texas will assist parents in filing insurance and obtaining coverage for processing fees.  Infants with a medical need are served regardless of ability to pay processing fees if milk is available. The Mothers’ Milk Bank of North Texas has a sliding scale payment.

Discharging a baby from the hospital on donor human milk.

It is important for us to speak to the parents when a baby is going home from the hospital on donor human milk. We will work with the parents to make sure that they have a supply of milk before the baby is discharged.

Prescribing milk for a baby already at home.

The parents must have a prescription from the infant’s health care provider and have a medical need for the milk.

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

______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).

______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 as appropriate 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 the form.  Note that the Dates of Service are for 180 days.  One copy should be kept in your office chart and a copy faxed or mailed to MMBNT.



Examples of diagnoses of infants on donor human milk:

•    preterm birth- donor milk in hospital, intolerant of weaning to alternative
•    preterm birth- complications, feeding difficulties
•    short-gut syndrome
•    inborn errors of metabolism
•    failure to thrive
•    malabsorption
•    renal disease/failure
•    inborn errors of metabolism
•    prenatal exposure to narcotics or illegal drugs
•    severe allergies or intolerance to breastmilk substitutes
•    immunodeficiency disorders (lgA deficiencies, HIV, SCID)
•    pre- or post-surgical and immunity support for fragile infants
•    cardiac defects
•    bronchopulmonary dysplasia
•    post-surgical nutrition(gastroschisis, omphalocele, colostomy repair)
•    organ transplantation
•    prenatal exposure to narcotics or illegal drugs