Register a Managed Care Member

  • Client Information

  • 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, M62.81
  • 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 issued.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • A waiver obligation is the amount a person is obligated to contribute toward the cost of their Medicaid services.
  • Waivers can be categorized as: A&D Waiver, DD Waiver, EF Waiver, etc.
  • Referral Agency Information

  • Case Manager Information

  • Billing Details/Managed Care Oganization

  • Include any delivery instructions, food preferences or family/friend contacts for assistance.
  • This field is for validation purposes and should be left unchanged.