New York State Food Assistance Program Application Medical Tailored Meals
Complete this form to determine your eligibility for services and ensure your information is securely handled.
Applicant Information
Medicaid CIN Number
*
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Spoken Language
Please Select
English
Spanish
Arabic
Bengali
Chinese
French
Haitian Creole
Korean
Polish
Russian
Urdu
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Childcare Assistance
Do you currently receive childcare assistance?
Yes
No
What type of childcare voucher do you receive?
Please Select
ACS Child Care Voucher
HRA Child Care Voucher
Not sure
Other
Childcare Voucher Number
Childcare Provider / Daycare Name
Is your childcare voucher currently active?
Yes
No
Not sure
Would you like assistance with childcare voucher enrollment or renewal?
Yes
No
Referral Source
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Please check off any category that applies to you or a family member:
*
Please Select
Enrolled in Health Home Care Management
Pregnant
Had a miscarriage
Post partum (within the last 12 months)
Substance Use Disorder diagnosis
Serious Mental Illness diagnosis
chronic condition
Any other health condition
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Living Situation
Have you had a major life event since your last screening?
*
Yes
No
Other
What is your living situation today?
*
I have a steady place to live
I have a place to live today but I am worried about losing it in the future
I do not have a steady place to live
Housing Conditions
Housing Conditions (check all that apply)
Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above
Utilities
In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services?
Yes
No
Already shut off
Food Security
Within the past 12 months, you worried that your food would run out before you got money to buy more.
Often true
Sometimes true
Never true
Transportation
In the past 12 months, have you lacked reliable transportation to medical appointments, meetings, work, or daily living needs?
Yes
No
Work / School
Do you want help finding or keeping work?
*
Yes, help finding work
Yes, help keeping work
I do not need help
Do you want help with school or training?
*
Yes
No
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Optional Demographic Questions
Gender Identity
Please Select
Woman
Man
Non-binary
Transgender
Prefer to self-describe
Unknown
Decline to answer
Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Unknown
Decline to answer
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Middle Eastern or North African
Prefer to self-describe
Unknown
Decline to answer
Preferred Pronoun
Please Select
She/Her
He/Him
They/Them
Prefer to self-describe
Unknown
Decline to answer
Optional Safety Questions
How often does anyone physically hurt you?
Please Select
Never
Rarely
Sometimes
Fairly often
Frequently
Decline to answer
How often does anyone insult or talk down to you?
Please Select
Never
Rarely
Sometimes
Fairly often
Frequently
Decline to answer
How often does anyone threaten you with harm?
Please Select
Never
Rarely
Sometimes
Fairly often
Frequently
Decline to answer
How often does anyone scream or curse at you?
Please Select
Never
Rarely
Sometimes
Fairly often
Frequently
Decline to answer
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Household Information
Optional. Add each household member who will receive meals, then tap Add Another for more.
Household Members
Signature & Authorization
I would like to continue with a Navigator within the Social Care Network for further assistance. I understand this information may be securely shared for eligibility review and care coordination.
Electronic Signature
*
Submit
Should be Empty: