2025 FOOD OUTREACH REFERRAL FORM

Food Outreach -- Client Referral Form

3117 Olive Street St. Louis, MO 63103 Phone: 314-652-3663
To be completed by healthcare provider or case manager

Questions marked with an * are required.
Patient Information
First Name*
Last Name*
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

Zip
Phone*
Alternate Phone
Preferred Language if not English
Check all that apply:*

MaleFemaleTransgender (M-F)Transgender (F-M)Non-binary
Race / Ethnicity (Check all that apply)*

Black or African AmericanAmerican Indian or Alaskan NativeAsianHispanic or LatinxNative Hawaiian/Pacific IslanderWhiteUnknown / UnreportedOther
Household Income (per month)*
Number in household supported by income*
Treatment Plan
Primary Diagnosis*

CancerHIVAIDS
Cancer Type & Stage*
Date of Cancer Diagnosis*

MonthDayYear
Date
Patient must be in active cancer treatment to qualify for our services. Please note that maintenance therapy alone does not qualify as active cancer treatment.*

SurgeryChemotherapyRadiationImmunotherapyHospice / palliative only
If known, please specify medication(s) or regimen name(s):
Treatment Start Date*

MonthDayYear
Date
HIV/AIDS Diagnosis Date*

MonthDayYear
Date
Ryan White eligible?*

YesNo
CD4 count*
CD4 test date

MonthDayYear
Date
Viral Load*
Viral Load test date

MonthDayYear
Date
HIV/AIDS Adult Risk Factor*

Men who have sex with men (MSM)Injection drug user (IDU)HeterosexualHemophiliaBlood transfusionUnknownOther
Relevant Medical History*
Please describe any special needs or circumstances
Insurance Information
Medicaid*

YesNoApplied / PendingSpend downMC+UnknownDenied
Medicare

Part APart BPart DMedicare AdvantageMedicare supplement
Other Insurance / Private Insurance Company
Request Made By
Name (please include credentials LCSW, MD, RD, case manager etc.)*
Agency Name and Location*
Referrer Phone*
Referrer Email*
example@example.com
Treating Oncologist*
Oncologist Phone*
HIV/AIDS Physician Name*
HIV/AIDS Physician Phone*
Release of Information
By submitting this application, you are confirming that your patient / client has provided verbal consent for their personal health information to be shared with Food Outreach.*

My patient / client has provided verbal consent for the personal health information in this form to be shared with Food Outreach.
Signature of Referring Physician/Social Worker/Nurse/RD/Patient Navigator or Case Manager*

Clear
Once a referral is submitted, we will attempt 3 times to schedule an intake appointment. To expedite the process, please have the client call us to schedule:

Phone: 314-652-3663

Intake Coordinator: x1119

Dietitian: x1113

Dietitian: x1112

Thank you!
Should be Empty:

Food Outreach -- Client Referral Form

To be completed by healthcare provider or case manager

Treatment Plan

Insurance Information

Request Made By

Release of Information