MMBB Lab Partnership Interest Form

The Minnesota Milk Bank for Babies (MMBB) is a nonprofit organization working to provide pasteurized donor human milk to medically fragile babies in the greater Midwest area. We are hoping to approve more milk donors in your community and looking for laboratories that can perform blood draws as part of our screening process. Join us in our mission to help babies close to home.

All of our volunteer milk donors must complete a communicable disease blood screen and we are looking for help from your team! We send our donors a kit in the mail, complete with the blood vials, physician’s order, a pre-paid shipping label and instructions for the lab. The donor simply brings the kit to their nearby lab to have their blood drawn and shipped overnight to our testing facility, Memorial Blood Centers. We are not asking your team to perform any testing or processing. Download the MMBB Lab Kit Guide for more details.

In completing this form, you demonstrate an interest in collaborating with MMBB. Your responses are not considered an agreement but rather a starting point to forging a new partnership. If you have any questions, please email us or call 763-614-5091.

FACILITY INFORMATION

Facility Name

Lab Address

Building/Room/Suite/Floor/Unit

City

State/Province

Zip/Postal

Lab Phone No.

Line Type:

Direct

Main switchboard – ask for lab

Lab Leadership Team (check all that apply)

Lab Manager

Regional Lab Director (health system w/multiple sites)

Other (Accounting, Phlebotomist, etc.)Other (Accounting, Phlebotomist, etc.)

LAB MANAGER CONTACT INFORMATION

Name

First

Last

Title

Email

Phone No.

REGIONAL LAB DIRECTOR CONTACT INFORMATION

Name

First

Last

Title

Email

Phone No.

ADDITIONAL CONTACT INFORMATION

Name

First

Last

Title

Email

Phone No.

Add Remove

LAB COURIER INFORMATION

We include a prepaid, overnight FedEx shipping label in each lab kit. We simply ask that your lab team put the label on the box and ensure it gets to your send-outs department ASAP. This is a time sensitive step, as the kit needs to arrive at the testing lab (Memorial Blood Centers in St. Paul, MN) within 24 hours of the collection time.

Does your facility have a daily FedEx pickup?

Yes

No

FedEx Pickup Time

Describe your facility’s courier schedule. Are there only certain days of the week with scheduled FedEx pickups? If so, what days and times.

Are you able to schedule a FedEx pickup with advance notice?

Yes

No

If your facility is unable to provide a scheduled FedEx pickup, this puts the burden on the milk donor to drive the lab kit box a nearby FedEx location. We are looking to create partnerships with facilities that are able to arrange the courier pick-up. If you have questions about how this works, please email virginia-pollock@mnmilkbank.org.

LAB SCHEDULING

Donors must complete the blood draw on a Monday-Thursday, ideally in the morning. Our testing lab is not open during the weekend, so if drawn on a Friday, the sample will NOT be usable and the donor will have to be re-drawn.

**REMINDER: LAB KITS NEED TO BE OVERNIGHTED** In order for the lab kit to get to send-outs for same-day FedEx pick-up, please build in a generous buffer time to get the lab kit packaged and to the right place. Some days are just busy – we don’t want to run the risk of drawing too late in the afternoon and missing the pick-up.

Earliest blood draw time available

Latest blood draw time available

Does your lab accommodate walk-ins?

Yes

No

What is the preferred time for walk-ins?

Does your lab schedule appointments?

Yes

No

Appointments are:

Preferred

Required

Scheduling Phone No.

Are there specific phrases we can suggest donors say while scheduling the blood draw?

Are there any helpful tips we can provide to donors to ensure their blood draw goes smoothly?

Does your facility prefer to have physician orders faxed in advance of the blood draw appointment?

Yes

No

Lab Fax No.

Fax Instructions

PARTNERSHIP WITH MMBB

The information provided in this interest form is not an agreement. If your facility necessitates a more formal agreement, indicate this below. Please note that your answers are non-binding and merely assist us in better understanding your facility as we initiate the process of creating a new partnership.

Does your facility need a lab services agreement in place before providing services for MMBB?

Yes, our facility has an internal agreement form

No, our facility does not require an agreement form

Unsure

As a nonprofit organization, we ask that you consider a fair service charge for the venipuncture and handling fees. Please provide a general estimate of the anticipated cost below (on average, facilities charge $25-$30)

Waived – free for all milk donors

Waived – free for only certain outpatients

Unsure – to be determined

Estimated price ($):Estimated price ($):

Our milk donors are volunteering their time and breast milk for free – we don’t want them to get the bill! This frequently happens when they are patients in the system, as their health insurance is tied to their chart. Let’s create a system where the Milk Bank gets the bill every time.

Can you suggest a process that will ensure MMBB receives the bill?

Will your facility be creating a vendor/client account for billing the Milk Bank directly?

Yes

No

Unsure

Billing Address: Minnesota Milk Bank for Babies, 2525 Nevada Ave N, #304, Golden Valley, MN 55427
Phone Number: 763-546-8051
Fax Number: 763-546-8196
Executive Director: Linda Dech (linda.dech@mnmilkbank.org)

What additional information can we provide your team to help facilitate in creating the account?

How does your facility plan to invoice MMBB?

What information can we provide your team to help facilitate the billing process?

Please describe the scenario in which the fees will be waived:

Do have questions or concerns about pricing?

Use this space to ask additional questions or tell us more about your lab.

THANK YOU!

We appreciate you taking the time to answer these questions. This is an exciting opportunity to potentially partner together and provide an important service for our community. It takes a village to nourish and protect our most vulnerable and medically fragile babies. After you submit this form, we will contact your team about next steps.