• Medical Nutrition Therapy Referral

    Please fill out to the best of your ability to streamline initiation of MNT services. You may fill out for yourself, or on behalf of the member. Please note that eligibility for MNT is based on nutrition risk assessment. You and/or your client will be alerted and provided resources if ineligible.
  • Please note: membership is required for MNT services. If you or your client is not a member of Aliveness, the membership form below must be completed and submitted in addition to this form.

     

  • *Please complete the eligibility portion of the Open Arms application (below) and list Emily Ostrow as the medical provider for authorization. This must be completed prior to submitting this referral form. 

    https://www.openarmsmn.org/hiv-aids-application/

     

  • Eating Disorder Screening for Primary Care (ESP)

    The below questions are included to ensure that the appropriate care model and therapy is provided. The answers to the questionnaire will not diagnose an eating disorder, nor deem the member ineligible for MNT.
  • Medical Records

    To expedite care, if consenting to the release of information (below) and recent medical records are available, please fax to (612)822-9668 (HIPAA compliant) to the attention of Emily Ostrow, MS, RDN, LD
  • Release of Information

    Clinic use: please return fax back with below information requested. Contact The Aliveness Project Clinical Nutrition Manager at (612)564-2829 with questions.
  • Clear
  • This does NOT include chemical dependency (alcohol/drug use records), mental health records, housing, financial assisistance, or emergency contacts.
  • Should be Empty: