Insurance Order Request Form

Insurance Order Request Form
Thank you for choosing UC Milk Bank

This form is only for families with an approved medical necessity for UC Milk Bank donor milk and an active Letter of Agreement (LOA) with your insurance provider.

Please Note:

All order requests are subject to review and approval. If approved, you will receive a confirmation email. A team member will contact you if additional information or documentation is needed to process your request.

Parent/Guardian
Updated Letter of Medical Necessity, if requested by medical team
Insurance Coverage

Please notify UC Milk Bank in the case of recent changes to your Insurance Coverage.

Insurance Provider
Donor Milk Request

Orders placed Monday through Thursday by 11AM are shipped same day via FedEx Priority Overnight Delivery.
*No weekend deliveries available. Orders placed after Thursday 11AM will be shipped Monday for delivery Tuesday.

Order Request
ORDER LIMITS: Local Pickup 6 to 30 bottles, Shipping 30 bottles
Shipping Address
Street, City, State, Zip Code