FOOD OUTREACH REFERRAL FORM

Food Outreach -- Client Referral Form

3117 Olive Street St. Louis, MO 63103 Phone: 314-652-3663
To be completed by healthcare provider or case manager

Questions marked with an * are required.
Applicant Information
First Name *
Last Name *
Today's Date *

Month Day Year
Date
Date of Birth *

Month Day Year
Date
Address *

Address

Street Address Line 2

City State

Zip
Phone *
Alternate Phone
Best Time to Call
SSN *
Check all that apply: *

Male Female Transgender (M-F) Transgender (F-M) Non-binary
Race / Ethnicity (Check all that apply) *

Black or African American American Indian or Alaskan Native Asian Hispanic or Latinx Native Hawaiian/Pacific Islander White Unknown / Unreported Other
Diet Order (Food Allergies / Intolerances / Religious Restrictions)
SNAP (Food Stamp) Eligible

Yes No
Food Stamp Amount
Number of dependents in household / ages
Primary Diagnosis *

Cancer HIV/AIDS
Cancer Type & Stage *
Date Dx *

Month Day Year
Date
Treatment plan (check all that apply) *

Surgery Chemotherapy Radiation Hospice / palliative only
Most recent treatment date *

Month Day Year
Date
Status *

HIV AIDS
HIV/AIDS Dx Date *

Month Day Year
Date
Ryan White eligible? *

Yes No
CD4 count *
CD4 test date

Month Day Year
Date
Viral Load *
Viral Load test date

Month Day Year
Date
TB Test *

Positive Negative Other
TB test date

Month Day Year
Date
HIV/AIDS Adult Risk Factor *

Men who have sex with men (MSM) Injection drug user (IDU) Heterosexual Hemophilia Blood transfusion Unknown Other
HIV/AIDS Pediatric Risk Factor

Sexual abuse Perinatal transmission Unknown Other
Desired Pantry Access *

Food Outreach MadCAP
Relevant Medical History *
Insurance Information
Medicaid *

Yes No Applied / Pending Spend down MC+ Unknown Denied
Medicare

Part A Part B Part D Medicare Advantage Medicare supplement
Other Insurance / Private Insurance Company
Household Income (per month) *
Number in household supported by income *
Income Percent of Federal Poverty Line

100% 200% 300%
Please describe any special needs or circumstances
Name of Referring Physician/Social Worker/Nurse/RD/Patient Navigator or Case Manager *
Agency Name *
Practice Name and Location *
Referrer Phone *
Referrer Fax
Referrer Email *
example@example.com
Treating Oncologist and Location/Hospital *
HIV/AIDS Physician Name *
Clinic Name *
Oncologist Phone *
HIV/AIDS Physician Phone *
Oncologist Fax *
Applicant Release of Information
By submitting this application, you are confirming that your patient / client has provided verbal consent for their personal health information to be shared with Food Outreach. *

My patient / client has provided verbal consent for the personal health information in this form to be shared with Food Outreach.
Signature of Referring Physician/Social Worker/Nurse/RD/Patient Navigator or Case Manager *

Clear
NOTE: Referring health care worker or patient may call to schedule intake appointment, or patient will be contacted as soon as possible.

Phone: 314-652-3663

Dietitian: x113

Nutrition and Outcomes Manager: x112
Once referral is submitted, client must call to schedule their intake apppointment:

Phone: 314-652-3663

Dietitian: x113

Nutrition and Outcomes Manager: x112
Should be Empty:

Food Outreach -- Client Referral Form

To be completed by healthcare provider or case manager

Insurance Information

Applicant Release of Information