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Application Form

The application form collects referral and patient information for a meal delivery program for individuals diagnosed with congestive heart failure. It requests the referring medical professional to verify the patient's diagnosis and recent hospitalization, and confirms the patient's eligibility, willingness to participate in nutrition counseling, and consent to release their medical information to the program. Completing healthcare providers can refer eligible patients and should securely email the completed application.

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141 views

Application Form

The application form collects referral and patient information for a meal delivery program for individuals diagnosed with congestive heart failure. It requests the referring medical professional to verify the patient's diagnosis and recent hospitalization, and confirms the patient's eligibility, willingness to participate in nutrition counseling, and consent to release their medical information to the program. Completing healthcare providers can refer eligible patients and should securely email the completed application.

Uploaded by

api-603319031
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM

• Any of the following healthcare professionals can refer: CM, SW, MD, DO, NP, PA, LVN, RN,
CHW, or Pharm.D.
• Securely email completed application to: [email protected]

Medical Personnel Only

Section 1: Referral Information

Name of Case Manager/Social Worker/Health Care Professional: _________________________

Agency Name: __________________________ Phone Number: _________________________

Email: ___________________________________________

Section 2: Applicant Information

Patient Name: _______________________________________ Date of Birth: ______/______/________

Address: ______________________________ City: ____________________________Zip: _________

Phone Number: ____________________________Secondary Phone Number: ____________________

Email: _____________________________________________ Primary Language: ☐English ☐Spanish

Emergency contact (other than case manager or social worker): ________________________________

Relationship: _______________Phone Number: ___________________Email: ____________________

Patient Information

Gender
☐ _Male
☐ _Female
☐ _Trans ID

Housing
☐ Permanently housed
☐ Non-permanent housing
☐ Other

Veteran Status
☐ Veteran
☐ Not a Veteran
☐ Unknown

Height: _____ft ______in Weight: _______lbs Recent Weight gain_______ loss________ change
inlbs_________

Diet Order: ☐ _Heart Healthy (CHF) ☐ _Heart Healthy + Carb-Controlled (CHF+DM) ☐ _Heart Healthy +
Kidney-Friendly (CHF+CKD3-4)

(note: we cannot accommodate severe allergies of any kind)

Fluid Restriction? ☐ _Yes ☐ _No If yes, _____ml/ day

Client New York Cardiac Classification (optional, but helpful): ______________________________

***PROVIDE H&P, MEDICATIONS, AND LABS***

Section 3: Eligibility Information

1. Has the individual been enrolled in Medi-Cal for the past 12 months? ☐Yes ☐ _No

Medi-Cal Subscriber#: ____________________________ (Medi-Cal # begins with a “9”)

2. To participate, individuals must be diagnosed with CHF and have recently been admitted for any
condition.

A. Check all ICD-10 Heart Failure Codes that apply:

I50.1 - Left Ventricular I50.3 – _Diastolic (congestive) I50.4 – _Combined Systolic


failure, unspecified heart failure and
Diastolic heart failure
I50.2 - Systolic heart failure I50.30 - 33 Diastolic heart I50.40 – _43 Combined
failure Systolic and
Diastolic heart failure
I50.20 - 23 Systolic I50.9 – _heart failure, unspecified
heart failure

B. Secondary Diagnosis: ☐ _CKD1-2 ☐ _CKD3-4 ☐ _ESRD ☐ _Diabetes ☐ _COPD ☐ _Cancer ☐ _Other


(please specify):

3. To participate, individual must:

☐ Not be enrolled in a meal program that provides more than seven meals per week to patient
☐ Have an anticipated life expectancy of more than a year (eg. patients in palliative or hospice typically
cannot be accommodated – _use your best judgement)
☐ Have sufficient supports and ability to adhere to program protocols
☐ Have visited their primary care doctor or specialist in the past 12months (if no, individual does not
qualify)
☐ Have had at least one qualifying event (defined as inpatient stay, SNF stay, or ED visit) in last 12
months

Date(s) of discharge, if available (from hospital, SND, or ED): __________________________________

Reason for hospitalization: ________________________________

Agree that for the 12-week period of service:

☐ They are willing to partner with our dietitians to make dietary changes, which will include trying new
food items

☐ They will receive 14 frozen meals, plus breakfast bags (100% nutrition)

☐ They will decide to be home or have someone home to receive regular weekly or biweekly food
deliveries, or call CHIP at least a day in advance if unable to do so

☐ Be willing to participate in four Medical Nutrition Therapy sessions (two in-home, two by-phone –
_the first in-home session must begin within first two weeks of the program)

Primary Health Care Provider: ___________________________________________

Address: _______________________________________ Email: _______________________________

Fax: ___________________________________________ Phone: _______________________________


Section 4: Signatures

Referrer Name: I certify that the information reported in this document is true, accurate and has been
verified

Printed Name: ____________________________Signature: ________________________________

Title: _____________________________________________ Date: _______________


Patient Consent to Release Information

I authorize my medical provider/ referring party to release information about my medical condition to
Project Angel Food as a necessary part of my medical treatment, and to prevent nutrition-related
complications.

Patient Name: ______________________________________ Date of Birth: _____ / _____/ _____

Medi-Cal Subscriber # _________________ active for at least 12 months: Y N Phone: _____________

Patient Address: __________________________ City: ________________________ Zip: _____________

Patient Signature: _________________________________________ Date: _____ / ______ / ______

If unable to collect written consent, sign below to confirm verbal consent before submitting health
records:

_____________________________________________________________________________________
Signature & Title of Referring Healthcare Worker Date

_____________________________________________________________________________________
Signature & Title of Witness (client family, friend, or healthcare worker) Date

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