Meals For The Elderly Recipient Application

Meals For The Elderly Recipient Application
In order to help us process your application as quickly as possible, please ensure that all information is included before you submit. If you have any questions, please call Client Services at 325-655-9200 Ext. 111.

An incomplete application can cause a delay in the approval process.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Application
Referred by
Referrer's Phone Number

Area CodePhone Number
Recipient Name

First NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number

Area CodePhone Number
Primary Language
Email
example@example.com
Has the applicant ever received Meals For The Elderly before?
Home Health Provider
Home Health Provider Phone Number

Area CodePhone Number
What hours is the home health provider in the home? (Please put a time next to the days)
Monday
Ex: 3pm-4pm
Tuesday
Ex: 8am-10am
Wednesday
Ex: 3pm-4pm
Thursday
Ex: 8am-10am
Friday
Ex: 3pm-4pm
Doctor's Name
Doctor's Phone Number

Area CodePhone Number
List health problems
Ex: COPD, Diabetes, Unsteady Gait, Fractured Hip, etc.
Disabled
Condition
Length of Temporary Condition
Diet Type
If married, is spouse interested in applying for MFTE??
Spouse's Name

First NameLast Name
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Primary Language
Email
example@example.com
Has the applicant ever received Meals For The Elderly before?
Home Health Provider
Home Health Provider Phone Number

Area CodePhone Number
What hours is home health or provider/caregiver in the home? (Please put a time next to the days)
Monday
Ex: 10am-12pm
Tuesday
Wednesday
Ex:10am-12pm
Thursday
Friday
Ex:10am-12pm
Doctor/Physician
Doctor/Physician Phone Number

Area CodePhone Number
List health problems
Ex: Diabetes, Breast Cancer, Rheumatoid arthritis, Osteoarthritis, etc.
Disabled
Condition
Length of Temporary Condition
Diet Type
Next of Kin

First NameLast Name
Relation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Emergency Contacts:

Can be neighbor, relative, or friend (At Least 2, must be different from next of kin)
List Name's, Relation to You, Home and Work Numbers
Ex: Ronnie Seal, Brother, Cell (325)123-4567 Work (325) 456-1234
Number of Cats
Number of Dogs
If eligible, would you like to receive supplemental pet food?
Contributing for Meals
By Whom? Family/Self
Are you a Veteran or a spouse of a Veteran?
If yes, veteran of?
Do you currently receive VA benefts?
Do you have Medicare or Medicaid?
Do you have any other insurance?
Insurance Company
Company from which you retired from?
Did the Company from which you retired from have a Matching Donation Program?
Description of House/Location
Ex: Corner red brick house off of Chadbourne & 19th St.
Additional Comments
Should be Empty: