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OH FREE Meal Insurance Verification Questionnaires Referring Partner
HIPAA
Compliance
1
What Organization is referring the member?
*
This field is required.
Who is referring the member
Referring Organization
Referring Contact Name
Referring Contact Phone Number
Referring Contact Email Address
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2
What Type of Primary Insurance does your member have?
*
This field is required.
Medicare
Medicaid
Commercial Plan (non medicare/medicaid)
I do not have Health Insurance at this time
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3
Who is your members Medicaid Insurance provider?
*
This field is required.
Buckeye Community Health Plan
CareSource
Molina Healthcare
Paramount Advantage
United Healthcare Community Plan
AmeriHealth Caritas
Anthem
Humana Healthy Horizons
I have a different health plan
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4
Who is your members Medicare Insurance provider?
*
This field is required.
Aetna Medicare
Anthem Blue Cross
Cigna
Humana
Medical Mutual of Ohio
MediGold Health
United Healthcare
Wellcare by Allwell
I have a different health plan
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5
Members Insurance Information
*
This field is required.
Primary Health Insurance Provider (Example: Aetna, Anthem BCBS, United Health Care)
Primary ID number
Secondary Health Insurance Provider (if applicable)
Secondary ID number (if applicable)
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6
Is the member 60 years of age or older?
*
This field is required.
YES
NO
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7
What is your members Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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8
Does your member have any of these Health Conditions, Disabilities and or are Food Insecure?
*
This field is required.
Select all that apply
Alcohol Use
ALS
Arthritis
Asthma
Atrial Fibrillation
Behavioral/Mental Health Issues
Cancer
Congestive Heart Failure
COPD
Depression
Diabetes
Heart Disease
Hepatitis
High Blood Pressure
High BMI
High Cholesterol
HIV/AIDS
Kidney Disease
Multiple Sclerosis
Parkinson's Disease
Stroke
Osteoporosis
I have other health conditions
I don't have a health condition
Food Insecure
Disability
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9
Does your member have any difficulty completing daily living tasks?
*
This field is required.
Select all that apply
Meal Prep/Cooking
Cleaning
Driving
Shopping
Decision Making
Ambulation
Other
None of the above
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10
Has your member
recently left
either of these facilities?
*
This field is required.
A recent discharge could make you eligible.
Hospital
Nursing Facility
Acute Care
Behavioral Health/Rehab
None of these
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11
Is your member
at risk
of entering either of these facilities?
*
This field is required.
Being at risk could make you eligible.
Hospital
Nursing Facility
Acute Care
Behavioral Health/Rehab
None of these
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12
Does your member have access to a refrigerator?
*
This field is required.
Yes
No
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13
Is your member getting food delivered to their home through another community program?
*
This field is required.
Using another company for food delivery may affect your eligibility.
Yes
No
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14
Would your member like to move their services to N4L?
*
This field is required.
Using another company for food delivery may affect your eligibility.
Yes
No
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15
Members first and last name
*
This field is required.
First Name
Last Name
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16
Member or caretakers email address?
We will only use this for communication purposes. You will be opted out from receiving marketing emails.
example@example.com
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17
Member or caretakers phone number?
*
This field is required.
We will only use this for communication purposes. You will be opted out from receiving marketing calls.
Area Code
Phone Number
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18
What type of protein does your member enjoy?
*
This field is required.
We will send your first box for you based on your protein preferences
Turkey
Vegetarian
Chicken
Vegan
Kosher
Halal
Beef
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19
Once FREE meals are confirmed, where can we send the members meals?
*
This field is required.
Please enter your delivery address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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