• Food Support Application - Provider Change

    Please complete this intake form with your contact and health information.

  • Step 1: About you

  • Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Are you already receiving or signed up for food support through a Social Care Network?
  • Are you looking to change your current food support provider?

  • Submitting this form does not automatically change your current services. Our team will review and contact you.

  • You may only receive Social Care Network food support from one provider at a time. If you are not looking to change providers, you may not need to submit a new application.

  • Step 2: Medicaid & Health Conditions

  • Health Conditions (select all that apply)

  • HIPAA Authorization Notice
    By submitting this form below, you authorize Compass Care and its affiliates to use and disclose your protected health information for the purpose of care management services, including coordination of food support, meal delivery, and related social services. This authorization is voluntary but necessary to participate in the Social Care Network program. You have the right to revoke this authorization at any time by contacting us in writing.

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