ModifyHealth - Community Health

Find out here if you qualify for 12 weeks of free, healthy meals delivered to your door at no cost to you!

ModifyHealth has teamed up with many Medi-Cal plans across California to provide their Medicaid members with home-delivered healthy meals, fully covered by their insurance.

If you qualify, one of our team members will reach out to confirm your information and to get your meals on their way to you ASAP!

Important:
To qualify, you must enter your information as it appears on your official insurance card

Are you a caregiver filling this out for a potential member?(Required)
Caregiver's Name(Required)
Member's Name(Required)
Member's Date of Birth(Required)
Member's Shipping Address (no PO boxes please)(Required)
Member's Health Insurance Provider(Required)
Whose phone number is this?(Required)
If other, what is the contact's name?(Required)
Has the member been informed that a referral is being requested?(Required)
Do you have any of the following conditions?(Required)
Does the member have any of the following conditions?(Required)
Clear Signature
Use your mouse or finger to draw your signature above.
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*No Cost For Eligible Medi-Cal Members with Chronic Conditions

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Please share your information below and we'll help you get started.

A ModifyHealth community health worker will contact you to walk you through the next steps.

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