INSTRUCTIONS
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: HIV/AIDS

 

Eligibility for service is determined based on medical and nutritional status.

 

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 meals@openarmsmn.org.

CLIENT SIGNATURE (Provider may obtain verbal consent from client. If verbal consent is obtained, please indicate that when signing below.)

1. I understand that my information — including health information, income documentation, residence details,and health insurance/demographic information — may be subject to review by Hennepin County or Minnesota Department of Health officials. The information will be used to determine my eligibility and fulfil thefunding requirements of the Ryan White CARE Act.
2. I understand that Open Arms will provide me with information about nutrition, HIV, and additional resources within thearea upon request.

I understand that any medical information about me provided to Open Arms of Minnesota is confidential and will not be disclosed without my consent in this release.

I authorize my health care provider or social worker listed below to verify my health information for Open Arms of Minnesota and share information about me that is relevant to this service.

I also agree that staff of Open Arms of Minnesota may contact individuals I supply as additional contacts if needed to provide meal service, or in emergency situations.

This release will remain in effect for 12 months from the date below unless revoked in writing, or I am no longer a client of Open Arms of Minnesota.

CLIENT SIGNATURE (Provider may obtain verbal consent from client. If verbal consent is obtained, please indicate that when signing below.)

I, for myself, my successors, heirs, assigns, executors, administrators, spouse, next of kin, and caretakers:

• Take full responsibility for any physical, mental, or other health-related conditions that may affect me as a result of the delivery,receipt, and/or consumption of meals and other food provided by Open Arms. I agree that I will alert Open Arms if I have any concerns about the delivery process, the meals and food provided, or anything else related to the program;
• Acknowledge and understand that participation in Open Arms’ program, including but not limited to the delivery, receipt, and consumption of free meals and other food, is voluntary and that Open Arms is providing meals and other food to me and if requested, my child(ren) and my caretaker(s), free of charge. I freely elect to participate in the program;
• Know, and am aware of, the risks and dangers associated with my participation in Open Arms’ program in which I have chosen to participate. Said risks may include injury or accident to person or property, death, or other loss, including but not limited to foodborne illnesses and allergic reactions due to food allergens that may or may not arise due to cross-contamination in the kitchen from Open Arms’ use of nuts, gluten, and other potential allergens. Risks may also arise if food is not properly stored or handled after Open Arms delivers it. I assume any and all risks, whether known or unknown, while participating in Open Arms’ program;
• Know, and am aware that, due to the nature of Open Arms’ work and reputation, there is a risk that my neighbors, family, and/or friends may assume and/or discover that I have a serious illness, including but not limited to, HIV/AIDS, MS, ALS, CHF, COPD, ESRD, and/or cancer, if I participate in Open Arms’ program. I will not hold Open Arms responsible or liable if this happens;
• Agree to release, indemnify and hold harmless Open Arms of Minnesota and its affiliates, including any subsidiaries, agencies, successors or assigns and the officers, directors, employees, volunteers, and agents thereof (collectively “Open Arms”), from any and all responsibility or liability for injuries or damages incurred as a result of my participation in Open Arms’ program, including injuries or damages resulting from negligence on the part of Open Arms. However, nothing in this release should be construed to release any entity, including Open Arms, from liability for willful, wanton or intentional acts.

THIS DOCUMENT RELEASES OPEN ARMS OF MINNESOTA AND ITS RESPECTIVE SUBSIDIARIES AND AFFILIATES, OFFICERS, DIRECTORS, EMPLOYEES, VOLUNTEERS, AND AGENTS, FROM LIABILITY FOR BODILY INJURY, WRONGFUL DEATH, PROPERTY DAMAGE, INVASION OF PRIVACY, BREACH OF CONFIDENTIALITY, DEFAMATION, AND/OR OTHER CLAIMS AS SET FORTH HEREIN. I HAVE READ THIS DOCUMENT AND UNDERSTAND THAT I GIVE UP SUBSTANTIAL RIGHTS AND ASSUME ALL RISKS BY SIGNING IT AND I SIGN VOLUNTARILY.

Open Arms of Minnesota is a nonprofit that prepares and delivers medically tailored meals free of charge to Minnesotans with life-threatening illnesses. Our registered dietitians guide our trained chefs in developing delicious, made from scratch meals tailored to specific illnesses. We also deliver meals to caregivers and dependent children if needed. At Open Arms, we believe that food is medicine, and that the right food can make a critical difference in the health of our clients.

 

• Meals may be delievered to a home address or workplace within our delivery area or picked up at our Minneapolis office, our St. Paul office, or a satellite location once per week.
• Each weekly delivery includes fourteen meals, featuring entrees with vegetable sides, fruit, desserts, snacks, and more.
• Clients work with our nutrition team to choose from one of our menus, with options to possibly modify further based on needs.
• Eligilbility for meals is based on information collected on the application form. A healthcare provider must verify illness and medical history.

 

What are my responsibilities as a client? To assure efficient, high quality service, clients are responsible for the following:

 

• Paperwork: Complete all necessary paperwork as requested in order to receive meals. This includes submitting an annual or semi-annual recertification form completed by you and your healthcare provider which states your medical, treatment, and mobility status. If you do not submit recertification paperwork by the due date, Open Armsmay suspend your meal services until eligibility can be reassessed.
• Contact Info: Notify Client Services if your address or phone number changes.
• Cancellation and Missed Deliveries: You must follow the Missed Delivery Policy as described on page 8. If you will be unavailble for an extended period of time, such as vacation or hospitalization, you may pause your meal services until you return.
• You must treat all OAM staff, volunteers, and drivers with respect and courtesy. Any party receiving a delivery must be fully clothed.
• You are responsible to know and follow your diet restrictions. OAM will accommodate special diet restrictions if possible, but we are not an allergen free facility and cross-contamination may occur.
• OAM does not supply complete daily nutrition. You are responsible for supplying the rest of your daily food/nutrition needs. You can find additional food resources here: www.hungersolutions.org.

 

What are my rights as a client? As a client of OAM, you have the right:

• To be treated with dignity and respect.
• To be informed of any changes being made to the client policies and procedures.
• To confidentiality and to have the right protected by staff, volunteers and all others associated with OAM to the best of their ability.
• To have every reasonable effort made to accommodate special dietary needs and restrictions.
• To contact OAM if you have concerns or complaints about food, service, or treatment by staff or volunteers and to be informed of the Grievance Procedure.
• To provide input, suggest changes, offer criticisms, and comments.
• To receive interpreter services at no cost to you.

Data Privacy Policy: When you agree to participate in this meal-delivery service provided by Open Arms of Minnesota, you will be asked to provide information that is entered into a limited-access, centralized database at the time of enrollment and periodically thereafter. As required by contractual agreements the program may also provide personally identifiable information to MDH, MN-DHS, and HC-HSPH Ryan White Program.

Open Arms of Minnesota will maintain your confidentiality at all times. Any identifying information obtained in connection with your participation in Ryan White funded services will only be disclosed to other providers with your written consent.
You will not be identified or identifiable in any written reports or publications.

Any information you give is voluntary and will not be released without your knowledge or consent except under specific circumstances. You may refuse to provide any of the information requested; however, refusal to provide information required for the provision of services may result in restriction of access to Ryan White services. You have privacy rights under the Minnesota Government Data Privacy Act and the federal Health Information Portability and Accountability Act (HIPAA). These laws protect your privacy and enforce your right to know about the information you are asked about yourself while accessing services.

What is the grievance procedure? As a client, you have the right to contact OAM with concerns. If a client believes they have been treated unfairly by Open Arms:

1. Client should seek to resolve any disagreement or dispute with the person involved, whether staff, volunteer, or other person associated with OAM. You may call Client Services staff at 612-767-7333.
2. If not resolved, the client should contact the Client Advocate with a written grievance within 10 days. The Client Advocate will have 10 days to respond to the complaint.
3. If the above fails to resolve the situation, the grievance will be given to the Program Director for review and resolution. Action and recommendations will be made by the Program Director and communicated within 30 days of the written notice.

What is the non-discrimination policy? OAM will not discriminate against, or harass, any client or applicant for services because of race, color, creed, ethnicity, national origin, religion, disability status, veteran status, status with regard to public assistance, age, sex, sexual orientation, or marital status.

Missed Delivery Policy: We expect someone to be at your delivery address to accept the meals on your scheduled delivery day. Deliveries are generally made between 11:00 am and 2:00 pm; someone must be available to accept the delivery during the entire delivery window. For food safety reasons, we are not able to leave food unattended, even in a cooler or enclosed porch. You may give us an alternate delivery location, such as a neighbor or the office of your building (we will need a contact and will verify their willingness to be your alternate delivery location); alternate delivery arrangements must be made at least one business day in advance. An unexcused missed delivery is when we attempt to deliver your meals on your regularly scheduled day and no one is home to receive it. 

 

If you will not be home during your regular delivery time, please call us at least 2 business days in advance. We can either cancel or reschedule your delivery if we are going to your neighborhood another day. Telling a volunteer driver that you will not be home for delivery is not sufficient notice for a canceled delivery. You must speak with a Client Services staff member or leave a voicemail at 612-767-7333. If you will not be home during your delivery window due to a last minute change in your schedule, please call us no later than 8:00 am on the day of your delivery day and speak with a Client Services staff member or leave a voicemail. 

 

We are not able to safely redeliver the food that we attempt to deliver for you. To avoid waste, maintain our food costs, and respect our volunteers’ time, we will not re-deliver an unexcused missed delivery and we will not be able to provide meals to you that week. Consistently failing to inform Client Services that you will not be home to receive your meals will result in your meals being stopped. Your meal service will be stopped if you have three unexcused missed deliveries within a six month period. You will become ineligible for deliveries for a period of three months. If picking up meals at our building is a better fit with your schedule, you must call and speak with Client Services to make arrangements and will be expected to follow the meal pick-up policy described below. 

 

Clients who pick up meals at Open Arms: You are expected to pick up your meals once a week. If you cannot pick up your meals during the week, you must speak with a Client Services staff member or leave a voicemail at 612-767-7333. Failure to pick up your weekly meals without notice will be considered a missed pick-up. Your meals will be stopped after 3 unexcused missed pickups in a six month period and you will become ineligible for meals for a period of three months.

 

Weather-related Delivery Cancelations: We do our best to deliver your meals through all of Minnesota’s seasons. When weather is too harsh for our volunteer delivery drivers, we may cancel deliveries.

• On days of weather-related cancellations, we will notify you as soon as possible.
• We will reschedule your canceled delivery as soon as the weather allows.

CLIENT ACKNOWLEDGEMENTS

It is agreed that as a client of Open Arms of Minnesota:

• I authorize Open Arms of Minnesota to obtain information regarding my medical status from myhealthcare practitioners and case managers.
• I understand that information collected about me is used solely to provide me with proper nutrition andmeals. This information will not be disclosed to any sources without my prior written consent.
• I assume full responsibility for informing OAM of dietary restrictions, requirements, and changes.
• I agree to recertify every six months by submitting a recertification form and all requesteddocumentation on time.
• I understand that I must let OAM Client Services staff know as soon as possible of any changes inmedical status, nutritional needs, address, telephone number, or delivery instructions.
• I understand that for food safety, meals must be accepted by an individual and will not be left unattended.
• I understand that the delivered meals are for my consumption and may not be sold.
• I understand I must treat OAM staff, volunteers, and drivers with respect and courtesy. OAM will notserve anyone at a location where staff or volunteers may be endangered. This includes physical,verbal, or substance abuse by a client or anyone in the client’s household or building, or for any otherreason determined by OAM. Failure to abide by this guideline can result in the suspension of mealdeliveries for up to 90 days, or the termination of a client’s meal delivery service.

CLIENT AGREEMENTS 

1. I understand and agree to the description of services and consent to receive meals from Open Arms of Minnesota.
2. I understand and agree with the Client Responsibilities, Rights, and Grievance Procedures.
3. I understand and agree with the non-discrimination policy.
4. I understand and agree with the Missed Delivery Policy and understand weather-related cancellations.
5. I understand and agree with the Data Privacy Policy.
6. I understand and agree with the Client Acknowledgements.
7. I understand that this authorization will have the duration of 12 months from the date of my signature.
8. I understand all OAM guidelines and have received a client copy of this documentation.

APPLICANT SIGNATURE (Provider may obtain verbal consent from client. If verbal consent is obtained, please indicate that when signing below.)

Client: I understand that any information about me provided to OAM is confidential and will not be disclosed without my consent in this release. I authorize my health care provider to verify my health information and share information about me that is relevant to this service. I understand that my information may be reported to funding sources, but will be treated with utmost privacy.

Please provide the best way to contact your healthcare provider. We will use this information to reach out to them so they can complete the medical portion of this application. Only once the medical portion is completed will we be able to process the application. If you have any questions about this, please call Client Services at 612-767-7333.