Refer a Member We’re here to address your concerns and answer meal order questions. We’ll respond within 48 business hours to your inquiry. Compassus Self Referrals Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Register a Waiver Member Client InformationClient Name* First Last Medicaid Number*Gender*- New -MFUClient Phone*Alternate PhoneThis field is hidden when viewing the formDate of Birth Month Day Year Date of Birth* MM slash DD slash YYYY Client's Email Client Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code ICD10 Diagnosis Code*Diagnosis codes describe an individual's medical condition and are required on claims submitted by health care professionals to third party payers. Example: R69, I10, M62.81Start Date* MM slash DD slash YYYY Start date is the anticipated start date of the home delivered meal service. This date needs to match the authorization that will be issuedEnd Date* MM slash DD slash YYYY Last Service Date by Previous Meal Provider* MM slash DD slash YYYY Approved Units*Waiver ObligationA waiver obligation is the amount a person is obligated to contribute toward the cost of their Medicaid services.Waiver Type*Waivers can be categorized as: A&D Waiver, DD Waiver, EF Waiver, etc.Preferred Language*This field is hidden when viewing the formDiet Restrictions (If Applicable) Diabetes Low Fat Low Sodium Renal Gluten Restrictions Other: Specify in 'Special Instructions' text box below. Diet Restrictions (If Applicable)Diabetes Diabetes Low Fat Low Fat Low Sodium Low Sodium Renal Renal Gluten Restrictions Gluten Restrictions Other: Specify in 'Special Instructions' text box below Other: Specify in 'Special Instructions' text box below Referral Agency InformationPhoneFaxAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Case Manager InformationName* Full Name Email*Phone*FaxThis field is hidden when viewing the formAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Billing Details/Managed Care OganizationWaiver Issuing Organization*PhoneFaxAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is Prior Authorization Required for This Service?YesNoPrior Authorization NumberSPECIAL INSTRUCTIONS:Include any delivery instructions, food preferences or family/friend contacts for assistanceConsent I agree to the privacy policy.CAPTCHANameThis field is for validation purposes and should be left unchanged. California / Self Referrals Client InformationClient Name* First Last Member Number*Gender*- New -MFUPreferred Language*Client Phone*Alternate PhoneThis field is hidden when viewing the formDate of Birth Month Day Year Date of Birth* MM slash DD slash YYYY Client's Email Client Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code ICD10 Diagnosis Code*Diagnosis codes describe an individual's medical condition and are required on claims submitted by health care professionals to third party payers. Example: R69, I10, M62.81This field is hidden when viewing the formDiet Restrictions (If Applicable) Diabetes Low Fat Low Sodium Renal Gluten Restrictions Other: Specify in 'Special Instructions' text box below. Diet Restrictions (If Applicable)Diabetes Diabetes Low Fat Low Fat Low Sodium Low Sodium Renal Renal Gluten Restrictions Gluten Restrictions Other: Specify in 'Special Instructions' text box below Other: Specify in 'Special Instructions' text box below Does the Member have any Allergies?Referral Agency InformationAgency NamePhoneFaxAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Case Manager InformationName Full Name EmailPhoneFaxThis field is hidden when viewing the formAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Billing Details / Insurance Provider InformationInsurance Provider*PhoneFaxAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SPECIAL INSTRUCTIONS:Include any delivery instructions, food preferences or family/friend contacts for assistanceConsent I agree to the privacy policy.CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Compassus Recipient InformationRecipient Name* First Last Unique ID #*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred Language*Number of Meals per Shipment*7 Meals14 Meals21 Meals28 MealsFrequency of Delivery*WeeklyTwice MonthlyMonthlyNumber of Shipments*Shipping Urgency*Standard ShippingNext Day Air2-Day ExpressUse only if required for first shipment. Urgent shipping costs will be billed to partner. Standard shipping is free of charge.Meal Kit Selection*Classic MealsDiabetes Friendly MealsHeart Healthy MealsRenal Friendly MealsGluten Restricted MealsVegetarian MealsPartner Company InformationPartner Name*Contact Name* First Last PhoneEmail*SPECIAL INSTRUCTIONS:Include any delivery instructions or unique information for the recipient.Consent I agree to the privacy policy.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
