ProduceRx Information Request Form

1

Your Name* This field is required.

First Name

Last Name

2

If applying on behalf of someone else, what is their name?

First Name

Last Name

3

What is your birthdate? Or, what is the birthdate of the person you are applying on behalf of?

Date

4

E-mail

example@example.com

5

Phone Number* This field is required.

Area Code

Phone Number

6

Can this phone number receive text messages?* This field is required.

YESNO

7

Do you consent to receive text messages from the ProduceRx team? * This field is required.

YESNO

8

Are you or the person you are applying on behalf of insured by Medicaid/WA Apple Health? * This field is required.

YESNO

9

Are you or the person you are applying on behalf of a patient of Community Health of Central WA (CHCW)? (This can be for medical or dental)* This field is required.

YESNO

10

To qualify for ProduceRx, you need to have a qualifying diagnosis. Do you have one of the following diagnoses?* This field is required.Qualifying diagnoses include: Diabetes, pre-diabetes, high blood pressure, high cholesterol, overweight or experiencing obesity, severe osteoarthritis, pregnancy, gestational diabetes, Medicaid assisted treatment for opioid use disorder.

Yes

No

Not sure

11

If you wish to elaborate on your diagnosis please do so here.

12

Do you have reliable transportation?

Always

Sometimes

Rarely

Never

13

Do you agree to stay in communication with the ProduceRx team in regards to box distributions and education opportunities? * This field is required.

YESNO