Open Arms of Minnesota provides home-delivered medically tailored meals and nutrition services to clients free of charge. This application collects information required to determine eligibility.
This form is for clients with: Cancer, MS, ALS, ESRD (on dialysis), CHF, COPD, other diagnoses.
Eligibility for service is determined based on medical and nutritional status. Please note that clients with a diagnosis other than cancer, MS, ALS, ESRD, CHF or COPD are not guaranteed services as funding for other diagnoses is subject to funding availability.
Note: In order to submit this form, you will need to provide the email address or fax number of a doctor, nurse, medical case manager, or medical social worker. Please make sure to have this information ready before starting this form.
Step 1: Complete this client portion of the application form. Include a fax number or email address for a healthcare provider, and they will be sent the the medical portion of the application which will need to be completed as well.
Step 2: The healthcare provider will receive an email or fax with the medical portion of this form. They will need to complete and sign that form and return it to us before we can process your application.
Please note eligibility can only be assessed after both the client and medical portions of the application form are received.
QUESTIONS? Contact Client Services at 612-767-7333 or email@example.com.