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 receive communications by text message about (messaging use case. eg. my inquiry/marketing messages etc) from HomeStyle Direct. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply. You may review our Privacy Policy to learn how your data is used.CAPTCHANameThis field is for validation purposes and should be left unchanged.