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Western Health Advantage Medicare Home Delivered Meal Referral Form

The Western Health Advantage Medicare Home Delivered Meal Service Referral Form allows healthcare providers to refer patients for home-delivered meals. It includes sections for personal and contact information, meal plan selection, and dietary preferences. This form ensures that patients receive nutritious meals tailored to their medical needs after discharge.

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How do I fill this out?

To fill out the Western Health Advantage Medicare Home Delivered Meal Service Referral Form, start by gathering all necessary personal and medical information. Follow the form’s sections methodically, ensuring all fields are completed accurately. Finally, select the appropriate meal plan based on the patient's dietary needs.

How to fill out the Western Health Advantage Medicare Home Delivered Meal Referral Form?

1
Gather the necessary personal and medical information.
2
Fill in the member and referral details accurately.
3
Provide the meal recipient's contact information.
4
Select the desired meal plan and dietary preferences.
5
Submit the completed form via email or fax.

Who needs the Western Health Advantage Medicare Home Delivered Meal Referral Form?

1
Healthcare providers need this form to refer patients for home-delivered meals post-discharge.
2
Case managers use this form to coordinate meal services for their patients.
3
Patients with specific dietary requirements need this form to ensure they receive appropriate meals.
4
Discharge planners need this form to arrange for ongoing nutritional support for patients.
5
Care coordinators utilize this form to manage meal delivery for patients with medical needs.

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What are the instructions for submitting this form?

What is the purpose of this form?

Tell me about this form and its components and fields line-by-line.

What happens if I fail to submit this form?

How do I know when to use this form?

What are the instructions for submitting this form?

To submit the completed Western Health Advantage Medicare Home Delivered Meal Service Referral Form, you can email it to CRIntake@westernhealth.com or fax it to 916.568.0278. For any questions or inquiries, contact Member Service at 888.563.2250. Ensure all sections are accurately filled out before submission to avoid any delays in meal delivery.

What is the purpose of this form?

The Western Health Advantage Medicare Home Delivered Meal Service Referral Form is designed to streamline the process of arranging home-delivered meals for patients after discharge from a medical facility. The form ensures that healthcare providers can provide essential nutritional support to their patients, tailored to their dietary needs and medical conditions. By completing and submitting this form, healthcare professionals can help improve the overall well-being and recovery of their patients through consistent and appropriate meal delivery services.

Tell me about this form and its components and fields line-by-line.

The Western Health Advantage Medicare Home Delivered Meal Service Referral Form contains several key fields to be completed by healthcare providers. It includes sections for personal and contact information, meal plan selection, dietary preferences, and special instructions.

1. Today's Date: The date the form is being filled out.
2. Diagnosis/ICD-10 Code: The medical diagnosis or ICD-10 code of the patient.
3. Member ID#: The ID number assigned to the patient.
4. Person Making Meal Referral: The name of the individual referring the patient for meal services.
5. Organization Name: The name of the organization handling the patient's case.
6. Case Manager/Care Coordinator Name: The name of the case manager or care coordinator responsible for the patient.
7. Phone: The contact number of the case manager or care coordinator.
8. Email: The email address of the case manager or care coordinator.
9. Person Receiving Meals: The name of the patient receiving the meal services.
10. City, State, Zip Code, Apt/Unit: The address details of the patient.
11. Date of Birth: The birth date of the patient.
12. Gender (M,F,U): The gender of the patient.
13. Secondary Contact: Optional contact details in case the primary contact is unreachable.
14. Relationship to Meal Recipient: The relationship of the secondary contact to the patient.
15. Meal Plan Selection: The selection of the desired meal plan based on dietary needs.
16. Discharge Date from SNF, Hospital, Rehab: The date the patient was discharged from a medical facility.
17. Special Delivery Instructions/Allergens/Food Preferences: Any additional instructions or preferences regarding meal delivery.
18. Email Referral Form to: The email address to which the completed form should be sent.
19. Fax: The fax number to which the completed form should be sent.
20. Questions or Inquiries: Contact details for any questions or further information.
21. Number of Meals Approved: The total number of meals approved for the patient.
22. Discharged From: The name of the facility from which the patient was discharged.

What happens if I fail to submit this form?

Failing to submit the Western Health Advantage Medicare Home Delivered Meal Service Referral Form may result in patients not receiving the necessary nutritional support post-discharge. This can negatively impact their recovery and overall well-being.

Delayed Meal Delivery: Patients may experience delays in receiving their meals if the form is not submitted on time.
Inadequate Nutritional Support: Patients might not receive meals tailored to their dietary and medical needs.
Compromised Recovery: Lack of proper nutrition can hinder the patient's recovery process.

How do I know when to use this form?

Use this form when referring a patient for home-delivered meals after they have been discharged from a medical facility. It is essential for ensuring patients receive appropriate nutritional support.

1. Post-Discharge Meal Referral: For arranging meal services after a patient is discharged from a hospital, SNF, or rehab.
2. Special Dietary Needs: For patients with specific medical or dietary requirements.
3. Case Management Coordination: To help case managers coordinate nutritional support for their patients.

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