FOOD OUTREACH SELF-REFERRAL FORM

Food Outreach -- Self Referral Form

3117 Olive Street St. Louis, MO 63103 Phone: 314-652-3663
Please Note: For self-referrals, diagnosis information must be confirmed by a healthcare provider and income eligibility must be established prior to intake appointment.

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
How did you hear about Food Outreach?*

Google search / internet searchAd on the internetReferral from another agencyFrom healthcare providerOther
Primary Diagnosis*

CancerHIV/AIDS
Cancer Type & Stage*
Date Dx*

MonthDayYear
Date
Treatment plan (check all that apply)*

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)*
Due to federal grant requirements, proof of income is required for all applicants -- please upload proof of income below.
Number in household supported by income*
Upload proof of income (such as social security, pay stub, wage, or bank statements showing deposits of income to applicant's account)
Photo of proof of income (such as social security, pay stub, wage, or bank statements showing deposits of income to applicant's account)
Proof of income status*

I have provided proof of income using one of the above options (uploading an image or taking a photo)I have not provided proof of income. After submitting this application, I will mail my proof of income to Food Outreach, Attn: Melissa Brown; 3117 Olive Street, Saint Louis, MO 63103
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 signing this document, I voluntarily consent for the exchange of my health information between Food Outreach and my health care provider (named above) for the treatment purposes that qualify me for Food Outreach’s services. The information shared by my health care provider with Food Outreach may include HIV/AIDS status, psychiatric and mental health disorders, sexually transmitted diseases, and drug and alcohol use. I release my health care provider and Food Outreach from all liabilities and all claims pertaining to the release and disclosure of such information.*

I consent to the exchange of personal health information between Food Outreach and my health care provider (named above).
Applicant Name*
Applicant Signature*

Clear
If signed by personal representative, list authority of personal representative:
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 a referral is submitted, the client must call to schedule their intake appointment:

Phone: 314-652-3663

Dietitian: x1113

Nutrition and Outcomes Manager: x1112
Should be Empty:

Food Outreach -- Self Referral Form

Insurance Information

Applicant Release of Information