WAKEMED DONOR MILK PROGRAM AGREEMENT
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1 WAKEMED DONOR MILK PROGRAM AGREEMENT Dear Sir/Madam, To begin your participation in the program please read the following Donor Milk Program Fact Sheet (page 2). Keep this for your records. A prescription from the recipient s doctor is needed. Prescriptions and ALL required forms must be received by the WakeMed Mothers Milk Bank prior to milk being dispensed. The prescription should include the number of ounces per day and the number of days or donor milk as needed if specific dose is not given. You may fax this information to us at (919) or send it by mail using the address below: WakeMed Mothers Milk Bank 1900 Kildaire Farm Road Cary, NC Please complete this form, the WakeMed Donor Milk Program Agreement (page 1) along with the following attached forms: 1. Agreement for Use of Donor Milk (page 3) 2. Patient Registration (page 4) 3. Credit Card Authorization (page 5) 4. WakeMed General Consent (page 6) Please note that milk cannot be dispensed until ALL of the required documents (pages 1 & 3-6) and a prescription have been received. If you have additional questions regarding participation please contact the WakeMed Mothers Milk Bank at (919) I acknowledge by my signature below, my understanding of the WakeMed Donor Milk Program, and agree to accept financial responsibility for the milk received. I also understand that failure to comply with this agreement could result in the cessation of donor milk dispensation and placement of my account with an outside agency for collection of any balance due. Legal Guardian (print) Legal Guardian Signature Date: / / Time: : 1
2 DONOR MILK PROGRAM FACT SHEET Thank you for your interest in the WakeMed Mothers Milk Bank Donor Milk Program. Please read this information carefully and contact our office at (919) with any additional questions. The current price (processing fee) of donor milk is $5.00 per ounce, including shipping and handling. Pricing are subject to change without notice. Donor milk cannot be returned for credit. Participation in the program falls into one of two categories, (1) medical necessity or (2) elective. Both categories require a physician s order or prescription including the diagnosis to participate. Medical Necessity: WakeMed Mothers Milk Bank will file insurance for medically necessary donor milk only if pre-authorization is obtained by the account guarantor. Elective: WakeMed Mothers Milk Bank will not file insurance for patients receiving donor milk on an elective basis. The entire balance is patient responsibility. 2
3 AGREEMENT FOR USE OF DONOR MILK Human milk is the food of choice for infants and young children. Human milk provides optimal nutrition, promotes normal growth and development and reduces the risk of illness and disease. The unique composition of human milk which includes nutrients, enzymes, growth factors, hormones, immunological and anti-inflammatory properties has not been duplicated. When mother s own milk is not available or there is not sufficient volume, pasteurized donor human milk from a recognized donor milk bank is the next best option. Pasteurized donor human milk retains most of its bioactive properties, which protect the baby from infection while the nutritional components of the milk are the easiest for the baby to digest. The WakeMed Mothers Milk Bank provides donor milk. The milk bank follows the guidelines set forth by the Human Milk Bank Association of North America (HMBANA) to ensure the safest product possible is provided. All donors provide milk on a voluntary basis. Only healthy women who are non-smokers and have a healthy lifestyle are accepted as donors. All potential donors are triple screened, including verbal and written screen, contact with the mother s and baby s healthcare providers, and a blood screening. The blood screening for donors includes tests for HIV, HTLV, syphilis and hepatitis. All milk is cultured, pasteurized and re-cultured prior to being released from the milk bank. I understand the above information about pasteurized donor human milk. I,, Legal Guardian (print) am in agreement that my baby/child will receive pasteurized donor human milk. Child s Name Legal Guardian (print) Legal Guardian Signature Date: / / Time: : 3
4 PATIENT REGISTRATION MOTHER S INFORMATION Mother s Name or Guarantor SSN Mailing Address Home Phone Cell Phone Shipping Address Employer Name & Address BABY S INFORMATION Baby s Name (or recipient) Birth date Race Sex SSN Diagnosis (reason for needing milk) - DOCTOR S INFORMATION Ordering Physician s Name Office Phone Office Address 4
5 CREDIT CARD AUTHORIZATION I, authorize WakeMed Health and Hospitals to charge this credit card for pasteurized donor human milk dispensed to the legal guardian of. I agree to pay all charges incurred from / / until I notify the WakeMed Mothers Milk Bank that I will no longer be responsible for charges or until another form of approved payment is presented to the WakeMed Mothers Milk Bank. Self-Pay Information Credit Card Type (Visa, MasterCard, etc) Credit Card Number Name on card Expiration Date Security Code Billing Zip Code Card Holder Name Date: / / Card Holder Signature Time: : 5
6 WAKEMED GENERAL CONSENT 6
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