Home-Delivered Meal Service Referral Form

Today's Date

Meal Benefit Start Date

Diagnosis/ICD-10 Code

Member’s ID Number

Member’s Insurance

Authorization Number

Provider Making Meal Referral

Person Receiving Meals:

Name

Date of Birth

Address

Phone

City

State

Zip

Secondary Contact (if recipient unreachable):

Relationship to Recipient

Name

Phone

Number of Meals Approved

Authorization Start Date

End Date

Choose Your Diet Restriction

General Wellness - (Meets ⅓ Dietary Reference Intake, Dietary Guidelines)

Low Sodium- ‹700 mg/meal, although most are ‹500 mg/meal

Diabetic Diet- ‹700 mg/meal, ‹ 65g carbs, although most are 20-45g carbs

Renal Diet (CKD Stage 3&4)- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus, ‹25g protein

Dialysis Friendly- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus

Gluten Free- based on ingredient list, not a dedicated kitchen

Vegetarian Meals

Check Any Known Allergens

Milk

Fish

Shellfish

Tree Nuts

Eggs

Peanuts

Soy

Wheat

Specialized Meal Plan/ Menu Comments/ Special Delivery Instructions