Eligibility Quiz

I'm completing this questionnaire on behalf of: *

My client/patient My family/friend Myself

Which of these statements best describes the applicant? *

Living with HIV/AIDS Has at least one of the following life-threatening illnesses: cancer, MS, ALS, ESRD, CHF, or COPD Has been impacted by COVID-19 None of the above

The following is true for the applicant: *

Has a compromised nutritional status AND/OR is physically unable to shop/cook Neither of the above

Is the applicant willing to be a private pay client? *

Yes No

The applicant has the following: *

A CADI waiver An elderly waiver An alternative care waiver None of the above

Is the applicant willing to be a private pay client? *

Yes No