Community Supports Inquiry Form

*Required Fields – This information helps us expedite getting you the answers you need.

Thank you for your submission. You will receive a confirmation email with next steps.

Medi-Cal Member’s Health Plan Information

Please tell us the member’s Medi-Cal health insurance plan.

Health Insurance Company Name

Medi-Cal ID #

Medi-Cal Member Eligibility Questions

Please tell us which of the following applies to you. This information will be supplied to the member’s health insurance plan to confirm eligibility for meals under the CalAIM Community Supports program.

Does the member have one or more of the following nutrition-sensitive conditions listed below? Select all that apply. *

Cancer(s) Cardiovascular Disorders Chronic Kidney Disease Chronic Lung Disorders Pulmonary Conditions such as Asthma/COPD Heart Failure Diabetes or Other Metabolic Conditions Elevated Lead Levels End-Stage Renal Disease High Cholesterol Human Immunodeficiency Virus Hypertension Liver Disease Dyslipidemia Fatty Liver Malnutrition Obesity Stroke Gastrointestinal Disorders Gestational Diabetes High Risk Perinatal Conditions Mental/Behavioral Health Conditions Other

Relevant diagnosis code

Has the member recently discharged from a hospital or skilled nursing facility?

Is the member at high risk for hospitalization or nursing facility placement?

Does the member participate in a care management program – meaning they are enrolled in a program with a care manager, case manager or social worker such as Enhanced Care Management (ECM) or with their health insurance plan’s care management program? Does the member have extensive care coordination needs – meaning they require assistance from multiple health care providers, specialists, social services and/or caregivers to manage their health condition(s)?

Medi-Cal Member Contact Information

First Name

Last Name

Street Address

Apt/Unit

City

State

Zip Code

County

Phone

Phone Type *

Home Phone

Cell Phone

Date of Birth

Gender

Preferred Language*

English

Spanish

Other

Please indicate which of the following best describes the member and their need for medically tailored meals

Select all that apply *

I have mobility challenges or physical limitations that make it difficult for me to prepare and eat healthy foods.

Meals will help me to follow dietary guidelines for my chronic condition.

My doctor recommended that I eat a special diet, and Mom's Meals will help me to follow that diet.

Meals will allow me to eat regularly or not skip meals which improves my health and quality of life.

Meals will help me to focus on other aspects of my self-care like going to my doctor's appointments and taking my medication.

Meals are helping to improve my condition, and I want to continue to improve.

My doctor told me to stay on these meals.

Meals will help me to stay out of the Emergency Room, hospital or nursing home.

There aren’t a lot of healthy food choices at the stores where I usually shop.

Stores or food pantries with healthy foods are too far away or hard to reach.

I don’t have a car or other transportation to reach stores or food pantries that have healthy foods.

I don’t have enough time to shop or cook for healthy foods.

I don’t know how to cook healthy foods.

My cooking equipment or storage space is not enough to prepare healthy foods.

None of these apply to me.

Please indicate if the Medi-Cal member has any food allergies

If the allergen is contained anywhere in the meal kit, the meal will not be available.

Select allergens (check all that apply):

Milk

Egg

Fish

Shellfish

Tree Nuts

Sesame

Peanut

Soy

Wheat

Other

Please indicate who is filling out this form on behalf of the Medi-Cal member

Relationship to member

Secondary Contact Information

In the event we can't get hold of the Medi-Cal member, is there a secondary contact we can add to the client record?

Care Manager/Social worker Information

Do you have a care manager or social worker assigned to assist with your care needs?

How did you hear about us?

How did you hear about Moms Meals? If Other, Please Specify

I agree to Mom's Meals' Terms & Conditions.

Food As Medicine

California Community Supports Inquiry Form

Medi-Cal Member’s Health Plan Information

Medi-Cal Member Eligibility Questions

Medi-Cal Member Contact Information

Please indicate which of the following best describes the member and their need for medically tailored meals

Please indicate if the Medi-Cal member has any food allergies

Please indicate who is filling out this form on behalf of the Medi-Cal member

Secondary Contact Information

Care Manager/Social worker Information

How did you hear about us?

Service

Support

Company

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Our Food & Programs

Who We Serve

About Us

The Full Scoop

Food As Medicine

California Community Supports Inquiry Form

Medi-Cal Member’s Health Plan Information

Medi-Cal Member Eligibility Questions

Medi-Cal Member Contact Information

Please indicate which of the following best describes the member and their need for medically tailored meals

Please indicate if the Medi-Cal member has any food allergies

Please indicate who is filling out this form on behalf of the Medi-Cal member

Secondary Contact Information

Care Manager/Social worker Information

How did you hear about us?

The Full Scoop

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Understanding dysphagia

Quality nutrition helps support those navigating a rare disease diagnosis

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