Language
English (US)
Spanish (Latin America)
Referral Intake Form
Kindly complete this form to the best of your ability. Please note that certain insurance plans may require additional medical documentation. If you are a licensed medical professional, we request that you attach the relevant medical documentation to support the member's request.
Personal Information
Lead Source
Member's First Name
*
First Name
Member's Last Name
*
Last Name
Member's Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Member's Address (No P.O. Box please)
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Member's Phone Number
*
Please enter a valid phone number.
Member's Email
example@example.com
Can we text member?
*
Yes
No
Preferred Language
i.e., English, Spanish, Russian, Hmong, ESL, etc.
Insurance Information
Member's HealthPlan
*
Please Select
Anthem Blue Cross California
Central California Alliance for Health (CCAH)
Contra Costa Health Plan (CCHP)
Healthnet of California and Oregon
Inland Empire Health Plan (IEHP)
Kern Health Systems
Molina Healthcare of CA
Other
HealthPlan
Other HealthPlan
Please Select
CalViva
CalOptima
Imperial Health Plan
Kaiser Permanente
LA Care
Humana
Partnership Health Plan (PHP)
WellCare
Member ID #
*
Health Plan ID# or Medi-Cal #
Missing Member ID?
Yes
No
MSSP # (if applicable)
MSSP #
How did you hear about this benefit?
Please Select
Family/Friend/Caregiver Referral
Advertisement - Flyer/Poster/Mail
Social Media/Internet/Apps
Doctor/Clinic/Healthcare Worker/Dietitian
Hospital/Discharge Planner
Event
Case Manager/Social Worker/Community Health Worker
Modify Health - Representative/Presentation
ECM - Enhanced Care Management/CS - Community Supports
Community Based Organization
Health Plan
WIC Office/County Office/Medi-cal Office
School/College
Other
Medical History
Member's Height
*
Member's Weight
*
Does the member have one or more of the following medical conditions?
*
Alzheimer's Disease/Dementia
At Risk for Homelessness
Cancer
Chronic Kidney Disease / Renal Disease
Chronic Lung Disorder
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Diabetes, Type 1
Diabetes, Type 2
Enrolled in ECM (Extensive Care Coordination Needs)
Fatty Liver Disease / NAFLD
Gastrointestinal (GI) Disorders
Gestational Diabetes
Heart Disease / Cardiovascular Disease
Hepatitis C
High Blood Pressure / Hypertension (on meds)
High Cholesterol
High-Risk Pregnancy
History of Substance Abuse
HIV / AIDS
Obesity
Post Partum
Recent Major Surgery/Trauma
Severe Mental Health Disorder / Behavioral Health Disorder
Stroke or History of Stroke
Other
Other Medical Conditions
Please list your current medications, if any:
Have you recently been hospitalized or discharged from a skilled nursing facility?
*
YES
NO
Discharge Date
-
Month
-
Day
Year
Date
Are you currently enrolled in ECM?
*
Yes
No
Unknown
Are you able to consume solid foods?
*
Yes
No
Note: meals are only available in solid foods with regular texture, and at this time we do not offer any modifications (e.g. chopped, pureed).
*
I understand that meals are regular texture only and feel safe receiving meals.
Please list any clinically documented food allergies:
*
No Known Food Allergies
Beans - BE
Bell Pepper - BP
Chicken - CH
Cilantro - CL
Curry - CY
Dairy - DI
Eggplant - EP
Eggs - EG
Fish - FS
Garbanzo Beans - GZ
Garlic - GA
Gluten - GL
Lamb - LB
Mushroom - MR
Olives (pieces) - OL
Onions - ON
Pork - PK
Red Meat - RM
Rice - RC
Sesame - SE
Shellfish - SS
Soy - SY
Spicy - SP
Squash - SQ
Tree Nuts - TN
Turkey - TK
Wheat - WH
Do you have a safe place to store and heat meals?
*
Yes
No
Anything else you would like us to know about your medical history?
Provide any additional information here
Documentation & Attachments
Attach medical documentation on disease state to expedite approvals
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Molina Medical History
Last A1C Results
Ex. 7.5%
Last A1C Result Date
-
Month
-
Day
Year
Date
EF Percentage (%)
Note: A healthy heart typically has an EF between 55-70%
Last Blood Pressure Reading
Ex. 120/80
Last Blood Pressure Reading Date
-
Month
-
Day
Year
Date
Chronic Kidney Disease
Stage 3
Stage 4
ESRD on HD
Serum Albumin Level
Note: A normal level is between 3.4g/dL to 5.4 g/dL
If has COPD: Is the member currently on oral steroids?
Yes
No
Are you up-to-date on your PCP visit?
*
Yes
No
Yes, Enter Date
Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?
Severe decrease in food intake
Moderate decrease in food intake
No decrease in food intake
Weight loss during the last 3 months?
Weight loss greater than 3 kg (6.6 lbs)
Does not know
Weight loss between 1 and 3 kg (2.2 and 6.6 lbs.)
No weight loss
Mobility
Bed or Chair bound
Able to get out of bed/chair but does not go out
Goes out
Has suffered psychological stress or acute disease in the past 3 months?
Yes
No
Neuropsychological problems
Severe dementia or depression
Mild Dementia
No psychological problems
Please indicate the member’s Shopping and Food Preparation abilities below:
Takes care of all shopping needs independently
Shops independently for small purchases
Needs to be accompanied on any shopping trips Completely unable to shop
Plans, prepares, and serves adequate meals independently
Prepares adequate meals if supplied with ingredients
Heats/serves prepared meals or prepares meals but does not maintain adequate diet
Needs to have meals prepared and served
Does the member currently have In-Home Supportive Services (IHSS)?
Yes
No
Unknown
Is the member currently receiving any of the following supplemental food sources? (Check all that apply)
CalFresh or other food/nutrition programs
Special Supplemental Benefits for the Chronically Ill (SSBCI)
WIC
Unknown
Secondary Contact
Caregiver's Name
First Name
Last Name
Caregiver's Phone Number
Please enter a valid phone number.
Primary Care Physician
PCP Phone Number
PCP Phone Number
PCP Fax Number
PCP Fax Number
Referring Provider Organization
Ex: ABC Hospital, Anytime Agency, etc.
County Served
Provider County
Referring Provider/Case Manager
First Name
Last Name
Referring Provider/Case Manager's Phone
Please enter a valid phone number.
Referring Provider/Case Manager's Email
example@example.com
Note: If the member is under 18 years of age, then please provide guardian's name and/or relationship to the member.
Relationship & Name of the guardian
I consent—or, if under 18 years of age, my legal guardian consents—to receiving services and communications via text and phone from ModifyHealth. I also authorize ModifyHealth to use and disclose my health information, as necessary, to coordinate care, deliver services, and communicate with my healthcare providers, health plan, or other involved parties in compliance with applicable privacy laws, including HIPAA.
*
Optional: Enter email to received official copy of this MTM.
Healthcare Provider's Email
Submit
Submit
Please list any diagnosed food allergies:
Please list any food allergies, i.e.,nut allergy, peanuts, fish, dairy, soy, etc.
Primary Care Physician Contact Information - Phone/Fax/Email
Please enter valid phone number (xxx-xxx-xxxx), fax xxx-xxx-xxxx email (example@example.com).
Primary Care Physician Email Address
Caseworkers are highly recommended to provide medical documentation on disease state to expedite approvals
Browse Files
Drag and drop files here
Choose a file
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of
Please provide medical documentation on disease state to expedite approvals
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Should be Empty: