Optage Meal Services Referral Form

Optage Meals Referral Form
Phone: 651-746-8280
Fax: 651-746-8281
Optage Meal Services Referral Form
Date Form Submitted:

MonthDayYear
Client Information
Client - Full Legal Name*

First NameM ILast NameSuffix
Safe at Home Client? (MN Address Confidentiality Program)

YesNo
Safe at Home Name

First NameLast NameSuffix
Safe at Home Address

Address or PO Box

Lot Number

CityState

Zip Code
County
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Age:
Delivery/Legal Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
County*
Phone Number 1
Format: 000-000-0000.
Phone Type

HomeMobileBusinessFax
Phone Number 2
Format: 000-000-0000.
Phone Type

HomeMobileBusinessFax
Phone Number 3
Format: 000-000-0000.
Phone Type

HomeMobileBusinessFax
Email Address 1
example@example.com
Email Address 2
example@example.com
Referral Source
Referred by

First NameLast Name
Phone Number
Format: 000-000-0000.
Fax Number
Format: 000-000-0000.
Email
example@example.com
Referral Source Information
Referral Source Name:*

First NameLast Name
Organization:
If Other, Enter Organization Name:*
Referral Source Type*

Case ManagerEmergency ContactHealthcare CoordinatorFamily/Friend
Referral Source Address*

Street Address

Apartment or Unit Number

CityState

Zip Code
County*
Referral Source Phone 1*
Format: 000-000-0000.
Phone Type*

BusinessMobileFax
Referral Source Phone 2
Format: 000-000-0000.
Phone Type

BusinessMobileFax
Referral Source Phone 3
Format: 000-000-0000.
Phone Type

BusinessMobileFax
Referral Source Email Address*
example@example.com
Emergency Contact
EMERGENCY CONTACT NAME*

First NameLast NameSuffix
Relationship*
Address

Street Address

Apartment or Unit Number

CityState

Zip Code
Contact Type*

Emergency ContactResponsible PartyDelivery Contact
Phone Number 1*
Format: 000-000-0000.
Phone Type*

HomeMobileBusinessFax
Phone Number 2
Format: 000-000-0000.
Phone Type

HomeMobileBusinessFax
Phone Number 3
Format: 000-000-0000.
Phone Type

HomeMobileBusinessFax
Email Address 1
example@example.com
Email Address 2
example@example.com
Payor Source Information
MEAL TYPE*

Frozen Meals (Delivered Weekly)Hot Meals (limited area, Ramsey & Washington Counties only-Clients must have a need for daily Hot meals)
PAYOR TYPE*

Pre-Paid EW Plan-Bridgeview, Health Partners, Medica or UCareTraditional Medicaid Waiver-AC, CADI, DD, ECS, EW or TBITitle III - Client must reside in Anoka, Hennepin, Ramsey or Washington county and be 60 years of age or olderPrivate Pay Client or CDCS - Monthly billing statement sent directly to client or CDCS Client
Payor Source*

ACCADIDDECSEWTBI
Payor Source*

BridgeviewHealth PartnersMedicaUCARE
*

CDCS (AC, ECS, EW)Client/Private PayCDCS (CADI, DD, TBI)WRAPS
Delivery Frequency*

Every WeekEvery 2 Weeks
Fiduciary Information
Contact Name:

First NameLast Name
Organization Name:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Email Address:
example@example.com
Meals per Delivery (Minimum of 5)*
Service Start Date: (service can only be started on Mondays):*

MonthDayYear
Date
Service lines need to begin on Mondays.

Once the client is routed, we will contact the client directly with the actual delivery date.
PMI/Medicaid Number :*
Primary Diagnosis Code:*
Physician Name:*

First NameLast NameSuffix
Physician NPI Number:*
Commercial Insurance Policy Number
Group Number (Medica)
Meal Information
Meal Plan Type

TraditionalAsian
Diet

Regular
Delivery Notes/Additional Information:
Optage Office Use Only
Date Entered in HDS

MonthDayYear
Date
Staff Name
Should be Empty:

Optage Meal Services Referral Form

Client Information

Referral Source

Referral Source Information

Emergency Contact

Payor Source Information

Fiduciary Information

Meal Information