ModifyHealth - Community Health

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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*
Member's Date of Birth*
example@example.com
Can we text member?*
Spanish, Russian, Hmong, ESL, etc.
Member's Shipping Address (no PO boxes please - California only)*
(This program is currently only available in California)

Member Insurance Info

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Health Plan ID# or Medi-Cal #
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Missing Member ID?
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Member Medical Information

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Please select all medical conditions that apply:*
Your insurance company requires a qualifying condition to provide free meals.
Is the member taking any medications?*
Does the member have any known food allergies?*
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:*
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Have you recently been hospitalized or discharged from a skilled nursing facility?
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MM slash DD slash YYYY
Are you currently enrolled in ECM?*
Enhanced Care Management (ECM) is a statewide Medi-Cal benefit for members with complex needs.
Are you able to consume solid foods?*
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.*
Do you have a safe place to store and heat meals?*

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.
MM slash DD slash YYYY
(If not known, please provide your best guess)
(This is your Ejection Fraction %, which measures the % of blood pumped out of the heart's main pumping chamber)
MM slash DD slash YYYY
If you suffer from Chronic Kidney Disease, please select one of the following:
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For those with COPD, is the member currently on oral steroids?
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Are you up-to-date on your PCP visits?
(A PCP is your Primary Care Provider)
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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?
Any weight loss during the last 3 months?
How is member's current mobility?
Has member suffered psychological stress or acute disease in the past 3 months?
Any of these neuropsychological problems?
Please indicate the member's Shopping and Food Preparation abilities below:
Does the member currently have In-Home Supportive Services (IHSS)?
Is the member currently receiving any of the following supplemental food sources? (Check all that apply)
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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
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Who is Member's Current Primary Care Physician?

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Referring Provider/Organization Info (if applicable)

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Ex: ABC Hospital, Anytime Agency, etc.
Referring Provider/Case Manager
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Relationship & Name of the guardian
Communications Consent
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Clear Signature
^^ PLEASE SIGN IN THE BOX DIRECTLY ABOVE^^
Use your mouse or finger to draw your signature as best as you can.
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Healthcare Provider's Email
Please click SUBMIT to complete your enrollment.
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*No Cost For Eligible Medi-Cal Members with Chronic Conditions

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For example: 805-555-5555

Want to see if you qualify for free meals? Click here instead.

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