FOOD OUTREACH SELF-REFERRAL FORM

Food Outreach -- Self Referral Form

3117 Olive Street St. Louis, MO 63103 Phone: 314-652-3663
Please Note: For self-referrals, diagnosis information must be confirmed by a healthcare provider and income eligibility must be established prior to intake appointment.

Questions marked with an * are required.
Applicant Information
First Name
Last Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Address

Street Address Line 2

CityState

Zip
Phone
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Best Time to Call
Check all that apply:
Race / Ethnicity (Check all that apply)
Diet Order (Food Allergies / Intolerances / Religious Restrictions)
SNAP (Food Stamp) Eligible
Food Stamp Amount
Number of dependents in household / ages
How did you hear about Food Outreach?

Other
Primary Diagnosis
Cancer Type & Stage
Date Diagnosed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Treatment plan (check all that apply)
Most recent treatment date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Status
HIV/AIDS Diagnosis Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Ryan White eligible?
CD4 count
CD4 test date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Viral Load
Viral Load test date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TB Test

Other
TB test date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HIV/AIDS Adult Risk Factor

Other
HIV/AIDS Pediatric Risk Factor

Other
Desired Pantry Access
Relevant Medical History
Insurance Information
Medicaid
Medicare
Other Insurance / Private Insurance Company
Household Income (per month)
Due to federal grant requirements, proof of income is required for all applicants -- please upload proof of income below.
Number in household supported by income
Upload proof of income (such as social security, pay stub, wage, or bank statements showing deposits of income to applicant's account)
Photo of proof of income (such as social security, pay stub, wage, or bank statements showing deposits of income to applicant's account)
Proof of income status
Please describe any special needs or circumstances
Name of your healthcare provider who can verify your diagnosis (examples: physician, case manager, oncologist, nurse, social worker, etc.)
Agency Name
Practice Name and Location
Provider Phone Number
Format: (000) 000-0000.
Provider Email
example@example.com
Treating Oncologist and Location/Hospital
HIV/AIDS Physician Name
Clinic Name
Oncologist Phone
Format: (000) 000-0000.
HIV/AIDS Physician Phone
Format: (000) 000-0000.
Applicant Release of Information
By signing this document, I voluntarily consent for the exchange of my health information between Food Outreach and my health care provider (named above) for the treatment purposes that qualify me for Food Outreach’s services. The information shared by my health care provider with Food Outreach may include HIV/AIDS status, psychiatric and mental health disorders, sexually transmitted diseases, and drug and alcohol use. I release my health care provider and Food Outreach from all liabilities and all claims pertaining to the release and disclosure of such information.
Applicant Name
Applicant Signature
If signed by personal representative, list authority of personal representative:
Should be Empty:

Food Outreach -- Self Referral Form

Insurance Information

Applicant Release of Information