Patient Referral Form
Refer a patient to Tangelo’s medically tailored meal delivery program—available at no cost to eligible patients through Medi-Cal health plans like Blue Shield Promise, Contra Costa, Gold Coast, and IEHP. Our team will review the referral and follow up if any additional information is needed. This form is HIPAA-compliant and ensures the privacy and security of all protected health information (PHI).
Patient Information
*
Patient First Name
Patient Last Name
Patient CIN Number
*
Unique identifier used by your organization to refer to this patient - oftentimes from your EHR.
Patient Address / Food Delivery Address
*
Street Address
Street Address Line 2 (if applicable)
City
State / Province
Postal / Zip Code
Patient Email Address
Please provide the patient's email address so that Tangelo can contact them if they have been approved.
Patient Cell Phone Number
*
Please provide the patient's cell phone number so that Tangelo can contact them if they have been approved.
Is this patient able to receive text messages to the number provided above?
*
Yes
No
Patient Condition(s)
*
Depression
Cancer
High BMI (e.g. Overweight)
Stroke
Behavioral or Mental Health Issues
Substance Use
Heart Disease
Congestive Heart Failure
Osteoporosis
Maternal Health
Alcohol Use
Asthma
Atrial Fibrillation
COPD
High Blood Pressure (Hypertension)
High Cholesterol
Type 2 Diabetes
Other
Primary Diagnosis Code
*
ICD-10 Code
Additional Patient Information
Allergies, hospital discharge date, food security status, goals, etc.
Patient Insurance Information
All information should match the exact information on the patient's insurance card.
Medi-cal Plan
*
Please Select
Blue Shield Promise
Contra Costa Health Plan
Gold Coast Health Plan
Inland Empire Health Plan
Other Plan
Subscriber Name
*
Subscriber DOB
*
-
Month
-
Day
Year
Date
Primary Referrer Information
Please complete this section if you are making this referral on behalf of the patient's physician.
Name
First Name
Last Name
Role at Organization
Nurse, Social Worker, Case Manager, etc.
Phone Number
Please enter a valid phone number.
Fax Number
Email Address
Referring Provider Information
Please fill out the information for the physician referring the patient to Tangelo.
Clinic / Organization Name
*
Office Phone Number
*
Referring Provider Signature
Name
*
First Name
Last Name
Signature
Electronic Signature Date
*
-
Month
-
Day
Year
Date
Referring Provider NPI
*
Continue
Continue
Should be Empty: