HOP Referral Request
Please complete the following form to request a HOP referral. Please keep in mind that all information you submit in this form will be viewed by the McDowell Local Food Advisory Council HOP Team members and shared with necessary parties to determine eligibility.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Please choose your PHP
*
Please Select
Wellcare
United Healthcare
Healthy Blue
Amerihealth
Vaya
Partners
NOTE: If your PHP is not listed above, you do not qualify for HOP. Please visit www.foothillsfoodhub.org/resources to see food resources available to you!
Medicaid ID #
*
If you do not know your Medicaid ID number, please reach out to DSS.
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: