Register a Waiver Member

  • Client Information

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  • 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
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    Start date is the anticipated start date of the home delivered meal service. This date needs to match the authorization that will be issued
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  • 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.
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  • Diet Restrictions (If Applicable)

  • Referral Agency Information

  • Case Manager Information

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  • 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.

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