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*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

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

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

Black or African AmericanAmerican Indian or Alaskan NativeAsianHispanic or LatinxNative Hawaiian/Pacific IslanderWhiteUnknown / UnreportedOther
Diet Order (Food Allergies / Intolerances / Religious Restrictions)
SNAP (Food Stamp) Eligible

YesNo
Food Stamp Amount
Number of dependents in household / ages
Primary Diagnosis*

CancerHIV/AIDS
Cancer Type & Stage*
Date Dx*

MonthDayYear
Date
Treatment plan (check all that apply). Please note that maintenance therapy alone does not qualify. Patient must be in active treatment.*

SurgeryChemotherapyRadiationHospice / palliative only
Most recent treatment date*

MonthDayYear
Date
Status*

HIVAIDS
HIV/AIDS Dx Date*

MonthDayYear
Date
Ryan White eligible?*

YesNo
CD4 count*
CD4 test date

MonthDayYear
Date
Viral Load*
Viral Load test date

MonthDayYear
Date
TB Test*

PositiveNegativeOther
TB test date

MonthDayYear
Date
HIV/AIDS Adult Risk Factor*

Men who have sex with men (MSM)Injection drug user (IDU)HeterosexualHemophiliaBlood transfusionUnknownOther
HIV/AIDS Pediatric Risk Factor

Sexual abusePerinatal transmissionUnknownOther
Desired Pantry Access*

Food OutreachMadCAP
Relevant Medical History*
Insurance Information
Medicaid*

YesNoApplied / PendingSpend downMC+UnknownDenied
Medicare

Part APart BPart DMedicare AdvantageMedicare 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
Once referral is submitted, client must call to schedule their intake apppointment:

Phone: 314-652-3663

Dietitian: x1113

Dietitian: x1112
Once referral is submitted, client must call to schedule their intake apppointment:

Phone: 314-652-3663

Dietitian: x1113

Dietitian: x1112
Should be Empty:

Food Outreach -- Client Referral Form

To be completed by healthcare provider or case manager

Insurance Information

Applicant Release of Information