Register a Waiver Member

Client Information
Client Name*
First Last
Medicaid Number*
Gender*
Client Phone*
Alternate Phone
Date of Birth
Month
Day
Year
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, M62.81
Start 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 issued
End 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.
Diet Restrictions
- Standard Meals
- Diabetes
- Low Fat
- Low Sodium
- Renal
- Gluten Restrictions
- Other: Specify in 'Special Instructions' text box below.
Referral Agency Information
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Case Manager Information
Name*
First Last
Email*
Phone*
Fax
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Billing Details/Managed Care Oganization
Waiver Issuing Organization*
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is Prior Authorization Required for This Service?
Prior Authorization Number
SPECIAL INSTRUCTIONS:
Include any delivery instructions, food preferences or family/friend contacts for assistance
Consent
I agree to the privacy policy.
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Name
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Register a Waiver Member

Client Information

Referral Agency Information

Case Manager Information

Billing Details/Managed Care Oganization

Healthy meals delivered right to your door.

1-866-735-0921

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