Register a Waiver Member Client InformationClient Name* First Last Medicaid Number* Gender*- New -MFUClient Phone*Alternate PhoneHiddenDate 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 Obligation A 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* HiddenDiet 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*FaxHiddenAddress 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 Number SPECIAL INSTRUCTIONS:Include any delivery instructions, food preferences or family/friend contacts for assistanceConsent I agree to the privacy policy.CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
