Patient Referral Form

Patient Referral Form
Refer a patient to Tangelo’s medically tailored meal delivery program—available at no cost to eligible patients through select Medi-Cal and Medicaid health plans in California and North Carolina. For a full list of eligible plans, please review here.
Patient Information*

Patient First NamePatient Last Name
Patient CIN Number
Unique identifier used by your organization to refer to this patient - oftentimes from your EHR.
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)

CityState / 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?*

YesNo
Patient Preferred Language
Patient Condition(s)*

DepressionCancerHigh BMI (e.g. Overweight)StrokeBehavioral or Mental Health IssuesSubstance UseHeart DiseaseCongestive Heart FailureOsteoporosisMaternal HealthAlcohol UseAsthmaAtrial FibrillationCOPDHigh Blood Pressure (Hypertension)High CholesterolType 2 DiabetesOther
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.
Plan State*
We currently only work with select Medi-Cal and Medicaid plans located in California and North Carolina.
Medi-Cal Plan Name*
North Carolina Plan Name*
Other Plan
Subscriber Name*
Subscriber DOB*

MonthDayYear
Date
Primary Referrer Information

Please complete this section if you are making this referral on behalf of the patient's physician.
Name

First NameLast 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 NameLast Name
Signature

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Electronic Signature Date*

MonthDayYear
Date
Referring Provider NPI*
Should be Empty:

Patient Referral Form

Patient Insurance Information

Primary Referrer Information

Referring Provider Information

Referring Provider Signature