Final Step - Medi-Cal Required Info For Free Meals Program

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Great news! We have confirmed that your health insurance membership does offer free meals for qualifying medical conditions.

Please take a few minutes to enter the info we need below for final approval from your insurance company so we can get your free meals shipped to you right away.

Insurance Member Info

Member's Name*

First Last

Member's Date of Birth*

Month

Day

Year

Member's Email

example@example.com

Member's Phone Number*

Can we text member?*

Yes

No

Preferred Language? (if other than English)

Spanish, Russian, Hmong, ESL, etc.

Member's Shipping Address (no PO boxes please - California only)*

Street Address Address Line 2 City State ZIP Code

(This program is currently only available in California)

Member Insurance Info

Please select Member's HealthPlan*

Do you have any other HealthPlan?*

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What is your Member ID #?*

Health Plan ID# or Medi-Cal #

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Missing Member ID?

Yes

No

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If you participate in the Multipurpose Senior Services Program (MSSP), please provide your MSSP# here:

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How did you hear about this benefit?*

Member Medical Information

Member's Height*

Member's Weight*

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Member's Height*

Please select all medical conditions that apply:*

Alzheimer's Disease/Dementia

Cancer

Chronic Lung Disorder

Chronic Kidney Disease / Renal Disease

COPD (Chronic Obstructive Pulmonary Disease)

Congestive Heart Failure (CHF)

Diabetes, Gestational

Diabetes, Type 1

Diabetes, Type 2

Fatty Liver Disease / NAFLD

Gastrointestinal (GI) Disorders

Hepatitis C

HIV / AIDS

High Blood Pressure / Hypertension (on meds)

High Cholesterol

High-Risk Pregnancy

History of Substance Abuse

Obesity

Recent Major Surgery/Trauma

Stroke or History of Stroke

Heart Disease / Cardiovascular Disease

Post Partum

Severe Mental Health Disorder / Behavioral Health Disorder

At Risk for Homelessness

Other

Your insurance company requires a qualifying condition to provide free meals.

Any Other Medical Conditions?*

Is the member taking any medications?*

Yes

No

Does the member have any known food allergies?*

Yes

No

Any food-related medication interactions we should know about?

Provide any additional information here

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Please list your current medications, if any (optional):

Medication

Dose ex. 15mg

Frequency, ex. daily, as needed, etc.

To add additional medications, click the + next to the previous row.

Please list any clinically documented food allergies:*

Chicken - CH

Dairy - DI

Fish - FS

Gluten - GL

Olives (pieces) - OL

Pork - PK

Sesame - SE

Spicy - SP

Turkey - TK

Beans - BE

Cilantro - CL

Eggplant - EP

Garbanzo Beans - GZ

Lamb - LB

Onions - ON

Red Meat - RM

Shellfish - SS

Squash - SQ

Wheat - WH

Bell Pepper - BP

Curry - CY

Eggs - EG

Garlic - GA

Mushroom - MR

Peanuts - PN

Rice - RC

Soy - SY

Tree Nuts - TN

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Have you recently been hospitalized or discharged from a skilled nursing facility?

Yes

No

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Discharge Date*

MM slash DD slash YYYY

Are you currently enrolled in ECM?*

Yes

No

Unknown

Enhanced Care Management (ECM) is a statewide Medi-Cal benefit for members with complex needs.

Are you able to consume solid foods?*

Yes

No

Note: meals are only available in solid foods with regular texture, and at this time we do not offer any modifications (e.g. chopped, pureed). Member must agree to the following statement to remain eligible for free meals.*

Yes, I understand that meals are regular texture only and feel safe receiving meals.

Do you have a safe place to store and heat meals?*

Yes

No

Molina or Inland Empire Health Plan

Molina and IEHP insurance providers request the following info to determine your eligibility. Please fill out as much as you can to improve your eligibility.

What were your last A1C Results?

Last A1C Result Date?

MM slash DD slash YYYY

(If not known, please provide your best guess)

What was your last EF Percentage (%) - if known

(This is your Ejection Fraction %, which measures the % of blood pumped out of the heart's main pumping chamber)

What was your last Blood Pressure Reading?

Last Blood Pressure Reading Date?

MM slash DD slash YYYY

If you suffer from Chronic Kidney Disease, please select one of the following:

Stage 3

Stage 4

ESRD or HD

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What is your Serum Albumin Level, if known?

For those with COPD, is the member currently on oral steroids?

Yes

No

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Are you up-to-date on your PCP visits?

Yes, Enter Date

No

(A PCP is your Primary Care Provider)

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Enter Date*

MM slash DD slash YYYY

Please enter approximate last visit date

Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

Severe decrease in food intake

Moderate decrease in food intake

No decrease in food intake

Any weight loss during the last 3 months?

Weight loss greater than 3 kg (6.6 lbs)

Does not know

Weight loss between 1 and 3 kg (2.2 and 6.6 lbs.)

No weight loss

How is member's current mobility?

Bed or Chair bound

Able to get out of bed/chair but does not go out

Goes out

Has member suffered psychological stress or acute disease in the past 3 months?

Yes

No

Any of these neuropsychological problems?

Severe dementia or depression

Mild Dementia

No psychological problems

Please indicate the member's Shopping and Food Preparation abilities below:

Takes care of all shopping needs independently

Shops independently for small purchases

Needs to be accompanied on any shopping trips

Completely unable to shop

Plans, prepares, and serves adequate meals independently

Prepares adequate meals if supplied with ingredients

Heats/serves prepared meals or prepares meals but does not maintain adequate diet

Needs to have meals prepared and served

Does the member currently have In-Home Supportive Services (IHSS)?

Yes

No

Unknown

Is the member currently receiving any of the following supplemental food sources? (Check all that apply)

CalFresh or other food/nutrition programs

Special Supplemental Benefits for the Chronically III (SSBCI)

WIC

Unknown

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Caregiver Info (skip if not applicable)

If you have a caregiver, enter that info here (if not, please click NEXT)

Caregiver's Name

First Last

Caregiver's Phone

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Who is Member's Current Primary Care Physician?

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Primary Care Physician

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Primary Care Physician - Phone Number (if known)

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PCP Fax Number

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Referring Provider/Organization Info (if applicable)

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Referring Provider Organization

Ex: ABC Hospital, Anytime Agency, etc.

County Served

Referring Provider/Case Manager

First Last

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Referring Provider/Case Manager's Phone

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Referring Provider/Case Manager's Email

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Note: If the member is under 18 years of age, then please provide guardian's name and/or relationship to the member.

Relationship & Name of the guardian

Communications Consent

I consent - or, if under 18 years of age, my legal guardian consents - to receiving services and communications via text and phone from ModifyHealth. I also authorize ModifyHealth to use and disclose my health information, as necessary, to coordinate care, deliver services, and communicate with my healthcare providers, health plan, or other involved parties in compliance with applicable privacy laws, including HIPAA.

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I consent—or, if under 18 years of age, my legal guardian consents—to receiving services and communications via text and phone from ModifyHealth. I also authorize ModifyHealth to use and disclose my health information, as necessary, to coordinate care, deliver services, and communicate with my healthcare providers, health plan, or other involved parties in compliance with applicable privacy laws, including HIPAA.*

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Optional: Enter email to received official copy of this MTM.

Healthcare Provider's Email

Please click SUBMIT to complete your enrollment.

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