Fillable Community Servings Home Delivered Meals Program

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Community Servings Home Delivered Meals Program

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Re
vised: January 2020
Community Servings Home Delivered Meals Program
Application Checklist
C
ommunity Servings provides free home delivered meals to clients at a critical stage of a life-threatening illness. A
weekly bag of meals typically contains 5 entrees, 5 salads, 4 soups, yogurt, fresh fruit, desserts and a quart of milk.
To determine your eligibility, please provide the following documentation:
Certification Form – Please have your doctor, nurse practitioner, or other healthcare professional
complete the Certification Form and provide a copy of your most recent laboratory results (preferably from
within the past 6 months), medical note from a recent visit, and a list of current medications.
*Fax to Client Services at 617-522-7770
Re
cent Lab Results
For applicants with HIV/AIDS, include CD4 and Viral Load lab results
F
or applicants with Diabetes, include A1C lab results
C
urrent Medications List
Copy of recent Medical Note with Problem List
Intake Packet – Please complete in full, sign and date.
Client Agreement – Read the Client Guidelines, sign and date the Client Agreement page.
Client Authorization for Release of Information – Please complete in full, sign and date.
Six Month Eligibility Form
(ONLY For applicants with HIV/AIDS or Mono-Infected Hepatitis C)
Submit a completed Six Month Eligibility Form
that shows proof of Income, Residency and Insurance
status. Supporting documentation is needed.
**Please note that only completed applications will be considered for review.**
Additional Information
1. Rev
iewing Eligibility: Once we have received the above documentation, your file will be reviewed for
eligibility.
I
f accepted, you will be asked to recertify once a year to continue your meal service.
2. Starting Services – If you are eligible to receive meals, a Client Service Coordinator will contact you regarding
a s
ervice start date. A Meal Service Plan (MSP) summarizing your delivery and diet details will be sent with your
first delivery. The MSP will need to be signed and returned within the first two weeks of your service if
reques
ted.
3. Delivery – Deliveries are made one day per week. Your delivery day is determined by Community Servings
based on geography. Exact delivery times may vary but someone must be home to receive your meals. Delivery
hours are: Monday- Friday 9:00am-6:00pm and Saturday 9:00am-2:00pm. For food safety, meals must be
accepted by an individual and will not be left unattended. Contact a Client Services Coordinator with any
quest
ions.
4. Nut
rition Inquiries – If you need to change the type of meal received or if you have nutritional questions,
please call our Nutrition Department staff at 617
-522-7777.
Please Contact Client Services with any questions at 617-522-7777!
Barbara Baez
Bilingual Client Services Coordinator
Carolyn Smith
Client Services Manager
Nia Faulk
Client Services Coordinator
Please Return Materials to:
Client Services
179 Amory Street
Jamaica Plain, MA 02130
FAX: 617-522-7770
Community Servings – 179 Amory Street - Jamaica Plain, MA 02130- Tel. 617-522-7777 - Fax 617-522-7770 Revised: June 2019
Community Servings
Certification Form
App
licant/Client Section: I hereby authorize my physician, nurse practitioner or physician assistant to release
information regarding my medical condition to Community Servings for the purpose of verifying my eligibility:
__________________________________ _________________________ ________________
Client Name Signature Date
Healthcare Provider Section:
C
ommunit
y Servings provides home delivered meals to clients at a critical stage of a life-threatening illness. On behalf of the
applicant/client noted above, please complete this form with all relevant information. The certification form, laboratory results
and medications list help us determine client eligibility and an appropriate diet. Thank you for your help in serving our clients!
Applicant/Client: Height: ___________ft. ______in. Weight: ______________
A. P
RIMARY DIAGNOSIS:
Check ALL that apply.
AIDS (CDC defined) (CD4 and Viral Load Required)
Y
ear of diagnosis: _________ (Required)
Mono-infected Hepatitis C
Year of diagnosis: _________ (Required)
HIV+ (CD4 and Viral Load Required)
Cancer (specify type): ___________________
Chemotherapy Ra
diation Therapy
Multiple Sclerosis (No labs required; Provide medical note.)
Cardiac Disease (
specify type):______________
CHF (
specify stage/severity):_____________
Diabetes II or Dia
betes I (HbA1C Required)
Lung Disease (
specify type): _______________
COPD (
specify stage/severity):____________
Renal Disease (
specify stage:) ______________
He
modialysis Peritoneal Dialysis
Other – Please specify: ___________________
B. M
EDICAL CONDITIONS RELATED TO ILLNESS:
Patient exhibited the following conditions in the past 30 days:
End of life care (no labs required) Please describe: _____________________________________________
Severe Diarrhea
Severe Nausea Se
vere Vomiting (check all that apply)
Oral or esophageal lesions limiting oral intake Pressure Ulcer – Stage:____________
Peripheral neuropathy significantly limiting standing and/or ambulation
Anemia Other condition causing severe fatigue or shortness of breath:___________________________
Wasting (unintentional weight loss of more than 5% usual body weight) Please describe:__________________
An opportunistic infection or neoplasm Please describe: ________________________________________
Dementia
M
ental Illness Please describe: ____________________________________________
Other Please describe: ____________________________________________________________________
C. M
OBILITY
: Factors that would impact a client’s ability to maintain a healthy diet & independent lifestyle.
Bed bound
Can’t stand for more than 15 minutes at one time
Can’t walk more than 50 feet at one time
My s
ignature certifies the medical information provided above.
_________________________________ ______________________________________ ____________
Physician/NP/PA Signature Clinic or Hospital Affiliation Date
_________________________________ ________________________ __________________________
Print or Stamp Name Telephone Number Fax Number
Please Fax the following to Client Services at 617-522-7770
Completed Certification Form
Recent laboratory results (within past 6 months)
Current medication list
Recent medical note with Problem List
click to sign
signature
click to edit
click to sign
signature
click to edit
C
li
ent
I
nformatio
n
Co
mmuni
ty
Se
rvin
gs
C
li
e
nt
In
take
F
or
m
First
Na
me:
----------
Middle
I
ni
tial:
__
_
L
as
t
Na
m e:
-----------
D
ate
of
B
ir
th:
__
/
_/
__
Ge
n
der:
D Male
D Female
D Transgender - D Male to F
ema
le
D Female to Male
Address:
____________________
_
Apt#:
_____
_
City:
_________
_
State:
P
rimary
Phone:
------------
Ot
h
er
Ph
one:
____________
_
Email=
-------------~
Demographics
Zip
Code
:------
Alterna
te
Co
n
tact
(Name
and
Number):
Primary
Language:
D English D Spanish D
Other
(please specify)
------
-
Race:
D African American/ Black D Asian D American Indian/ Alaskan Native D Native H awaiian/ Pacific Islander
D White/ Caucasian D
Other
(please specify)
________
_
H
ispanic
or
L
atino
/ a: D
Hi
spanic
or
Latino/ a D
Not
Hispanic
or
Latino/ a D
Unknown
/ Unreported
H
ispanic
Subgroup
: D Mexican, Mexican American, Chicano/ a D Puerto Rican D Cuban D
Another
Hi
spanic,
Latino/ a
or
Spanish origin
Asian
Subgroup:
D Asian Indian D Chinese D Filipino D Japanese D Korean D Vietnamese D
Other
Asian
Nati
ve H aw
aiian
/ Pacific I
slander
Subgroup:
D Native Hawaiian D Guamanian
or
Chamorro D Samoan
D
Other
Pacific Islander
Country
of
B
irth:
D USA D US Dependencies, including Puerto
Ri
co
D
Other
---------
H
ousing
and
I
ncome
In
formation
H
ousing
(y
ou
must
ch
oose
one):
D Permanent Housing
D Transitional Housing
D Emergency Shelter
D Substance Abuse Treatment Center
D Psychiatric Facility
D Incarcerated
D Temporarily Living with a Friend/ Family Member
D
Other
(please specify)
----------
0 Unknown/ Unreported
I
ha
ve
access
to: D Refrigerator D Stove D Microwave D
Oven
D Freezer D
None
D
Other
:
-------
Do
y
ou
have
someone
to
h
elp
y
ou?
D Visiting Nurse D H
ome
Health Aide D Family Member/ Friend
D
No
Help D
Other
(please specify)
____
_
I
ncome
Source
_________
_
Mont
hl
y I
ncome
________
_
Page
1
of
4
Commu
nity
Servings - 179 Amory Stre
et
-Jamaica Plain, MA 02130- Tel.
61
7-522-7777 - Fax 617-522-7770 R
evised
:
June
2019
Per
sonal
Id
en
tifi
cat
i
on
Mother's First
Name
:
-------------
Last four digits
of
Client's Social Security
Number
:
_______
_
---------------~
I
ns
ur
ance
In
fo
rm
at
i
on
H
ealt
h
In
s
ur
an
ce
Provider:
_____________
_
I
nsurance
Type
(chec
k
all
t
hat
a
pp
ly):
D
Other
Public Insurance D MassHealth (Medicaid)
D Medicare
D ConnectorCare
D Private Insurance
~
D Individual Plan D Employ
er
Plan
Specify
Plan:
--------
D VA, Tricare,
or
Other
Military Health Care
D Health Safety
Net
D
No
In
surance
D
Other
(speci
fy)
-------
D Are y
ou
a CCA (
Common
wealth Care Alliance)
One
Care
or
SCO
member?
If
so please call 61
7-
522-7777
to
speak
to
Client Services.
Em
erge
n
cy
Co
n
tac
t
Inf
o
rm
at
ion
E m
erge
ncy
Co
n
tac
t
Na
m e:
---------------R
elationship:
----------
Add
r
ess:
--------------------------------------
P
rimary
P
ho
ne:
-----------
Other
Ph
one:
___________
_
Is the emer
genc
y co
nt
act
awa
re
of
c
lie
n
t's
sta
tu
s or illness?
--------
Ref
erral
I
nfo
rm
at
ion
Ref
erral
So
u
rce
: D Self D Case Management D Substance Abuse Program D Homeless Service
D Health Center D Doctor, Nurse
or
Dietitian D Dialysis D Hospice D
Other
:
--------
Ref
erral
N am e:
-----------------
T itle:
____________
~
Ref
erral
Agenc
y:
________________________________
_
P
ho
ne:
__________
_
E m
ail
Add
r
ess:
--------------------
S
upp
o
rt
System s
(if
d
iffe
r
ent
from
referral
so
u
rce)
Name
of
P
rimary
Care
Phy
sician
:
________________
Ph
one:
---------
Age
nc
y/
C
lini
c:
----------------------
FAX:
---------
Name
of
Social
Wo
rk
er/
Case
Manager:
--------------
Ph
one
:---------
Age
ncy:
__________________
~
E
m
ail:
________________
_
Med
ical
Inf
or
m
atio
n
If
A
ID
S
or
HI
V+,
p
lease
indicate
expos
u
re
category
(c
h
eck
a
ll
that
ap
ply): D Men
who
have sex with
men
(MSM) D
Women
who
ha
ve sex with
women
(W
SW
) D Heterosexual contact D Injection drng use D Perinatal
transmission
D Hemophilia D Through blood, bl
ood
products, tissue D
Other
risk D
Unknown
If
A
ID
S
or
HI
V+:
each week,
how
often
do
y
ou
take all doses
of
y
our
H
IV
-related medications?
o Rarely (>4 doses missed) o
Sometimes (3-4 doses missed) o Frequently (1-2 doses missed) o Always (
no
doses
missed)
Page 2
of
4
Commu
nity
Servings - 179 Amory Stre
et
-Jamaica Plain, MA 02130- Tel.
61
7-522-7777 - Fax 617-522-7770 R
evised
:
June
2019
P
age 3 of 4
Community Servings – 179 Amory Street- Jamaica Plain, MA 02130- Tel. 617-522-7777 - Fax 617-522-7770 Revised: June 2019
Mental Health: Are you experiencing? □ Angry Outbursts □ Anxiety □ Poor Memory □ Insomnia □
Nervousness □ Poor appetite □ Depression
Have you been treated or are you currently being treated for: □ Schizophrenia □ Bipolar □ Depression
□ Drug/Alcohol Addiction (In recovery for how long?__________________ ) □ Other: _______________
Hospitalizations in the Past Year:
Date
Reason
Medical Center
Medical Follow ups: □ R
egular Check-ups □ Goes to the ER □ Only when ill □ Never □ Unknown
□ Other: ______________ □ Standing appointments (What days?):____________________________________
Nutrition & Diet Information
C
urrent Weight: ________________ Height: _______________
Questions
YES
NO
Do you have any food allergies?
If yes, please list each allergy and the type of reaction you have below:
Have you unintentionally lost weight in the past 6 months?
If yes, how much?
Have you unintentionally gained weight in the past 6 months?
If yes, how much?
Has your appetite changed in the last 6 months?
If yes, describe:
Do you have any problems chewing?
If yes, describe:
Do you have any problems swallowing?
If yes, describe:
Do you have nausea or vomiting?
If yes, how often and for how long?
Do you have diarrhea?
If yes, how often and for how long?
Do you drink Boost or Ensure?
What are the impacts of side effects from your medications? □ Severe □ Moderate □ Minimal □ No side effects
Describe side effects, if any:
P
lease write any other nutrition or food concerns here: ________________________________________
____________________________________________________________________________
P
age 4 of 4
Community Servings – 179 Amory Street- Jamaica Plain, MA 02130- Tel. 617-522-7777 - Fax 617-522-7770 Revised: June 2019
Our nutrition staff may contact you to review your responses with you.
Type of Diet: Please choose up to three (3) selections (Note: some meal combinations may not be possible)
□ Wellness – general healthy diet
□ Diabetic
□ Cardiac
□ Renal – kidney & diabetic
friendly
□ Children’s Wellness
□ Vegetarian – no meat, chicken or
fish
□ Pescetarian – no meat or chicken
(fish included)
□ Mild – low in spice and acid
□ Soft
□ Low Fiber
□ Low-Lactose
□ High Calorie/Protein
□ No Fish
□ No Nuts
□ No Red Meat
Milk:
□ Skim/nonfat □ 1% □ 2% □ Lactaid
□ I would like to be contacted by nutrition staff to discuss my diet selection or other nutrition concerns.
Please Note: We are not a food allergen-free facility. Meals may contain traces of nuts, fish, shellfish,
dairy, and/ or eggs. We are unable to accommodate gluten-free restrictions, wheat and soy intolerances or
any ot
her restrictions not listed above. We do not use pork products in any of our meals.
Persons in Household
C
ommunity Servings, in addition to the primary client, will provide meals to a caregiver or parent/spouse and any
children under the age of 18 years.
Relationship
Diet selection (see above)
Race
Gender
Date of Birth
Delivery Instructions
P
lease provide any relevant delivery information (e.g., gates, buzzers, codes, or standing appointments
such as dialysis):
________________________________________________________________________________________
________________________________________________________________________________________
Person completing the intake: __________________________________
Client’s signature: _____________________________________________ Date: ___________________
click to sign
signature
click to edit
Please keep for your files
Co
mmunity Servings – 179 Amory Street- Jamaica Plain, MA 02130- Tel. 617-522-7777 - Fax 617-522-7770 Revised: January 2020
Client Guidelines
Clie
nt Responsibilities, Rights and Grievance Procedure
What is Community Servings?
Community Servings’ mis
sion is to provide free home-based nutritional support to persons living with life
threatening illness, without regard for race, religion, gender, national origin, or sexual orientation. We are dedicated
to providing these services with care and compassion, in such a way as to promote dignity and self-sufficiency.
Eligibility for services is based on a certification form, which establishes the client’s acute life-threatening illness and
assesses a client’s need according to health and mobility implications.
What are my responsibilities as a client?
To assure efficient, high quality service, delivery clients are responsible for the following:
Paperwork: Complete all necessary paperwork as requested in order to receive meals.
Contact Information: Notify Client Services of any address or telephone number changes.
Delivery Schedule: Deliveries are made once a week on a prescribed day. Exact delivery times may vary but
someone must be home on the day of your delivery to receive your meals.
Delivery hours are: Monday –
Friday between 9:00am-6:00pm and Saturday 9:00 am-2:00 pm (unless other
delivery arrangements were made). If you have not received your meals by 5pm, please leave a message with
Client Services at 617-522-7777
Recertification: Once a year, or as needed, you will be asked to resubmit all paperwork and have your health
care provider fax in a yearly certification form which states a client’s medical and mobility status. Updates to some
paperwork is required on a six month basis.
Cancellation: Clients must call our Client Services department 24 hours in advance and no later than 8:00 am
on the day of delivery to cancel meals. If you will be unavailable for an extended period of time (such as a
va
cation or hospitalization) you may put your meals on hold and call Client Services to resume deliveries.
What are my rights as a client?
Community Servings shall honor the rights of each person receiving services. You have the right:
To be
treated with dignity and respect.
To be informed of policies and procedures concerning clients.
To have every reasonable effort made to accommodate special dietary needs and restrictions.
To confidentiality and to have that right protected by staff, volunteers and all others associated with the
agency.
To be informed of the Grievance Procedure.
To provide input, suggest changes, offer criticisms and comments.
To receive interpreter services at no cost.
What is the Grievance Procedure?
If a client believes that they have been treated unfairly by Community Servings:
C
lient should seek to resolve any disagreement or dispute with the person involved, whether volunteer,
staff, or others associated with the agency.
If this does not resolve the situation within 3 business days, the client should ask to speak with the Client
Services Manager. The Client Services Manager will make all attempts to resolve the situation and inform
the client of the results.
If the above fails, the client may call the Director of Programs. The Director of Programs will gather and
analyze all facts and both parties will be interviewed. The client will be informed of the results.
Community Servings may refer the client to a third-party mediator for negotiation, if needed.
Please keep for your files
Co
mmunity Servings – 179 Amory Street- Jamaica Plain, MA 02130- Tel. 617-522-7777 - Fax 617-522-7770 Revised: January 2020
Client Guidelines
Missed M
eal Delivery Policy
What happens if I miss a delivery?
We expect someone to be at your delivery address to accept the meals on your scheduled delivery day. An
un
excused missed delivery is when we attempt to deliver your meals on your regularly scheduled day and no one
is home to receive it. For food safety these meals must be thrown away; to avoid waste please call ahead to cancel
your delivery. We will not reschedule or redeliver an unexcused missed delivery.
If you will not be home during your regular delivery time, you must call our Client Services department at 617-
522-7777 at least 24 hours in advance and no later than 8:00 am on the day of delivery. Please leave a message on
voice mail and we will return your call as soon as possible.
C
onsistently failing to inform Client Services that you will not be home to receive your meals will result in
your meals being stopped. Your service will be stopped after 3 consecutive missed deliveries
Clie
nt Acknowledgements
It is agreed that as a client of Community Servings:
I authorize Community Servings to obtain information regarding my medical status from my healthcare
practitioners and case managers.
I understand that information collected about me is used solely to provide me with proper nutrition and meals.
This information will not be disclosed to any sources without my prior written consent.
I assume full responsibility for informing Community Servings of dietary restrictions, requirements and changes.
I agree to recertify once a year by submitting a new application.
I understand that I must let Community Servings know as soon as possible of any changes in medical status,
nutritional needs, address or telephone number.
I understand that I must review a Meal Service Plan. This document summarizes delivery and diet details. I
understand that I must sign and return the Meal Service Plan to Community Servings on a six month basis if
requested.
I understand that for food safety, meals must be accepted by an individual and will not be left unattended.
I understand that the delivered meals and supplements are for my consumption and may not be sold.
I understand that Community Servings will not serve anyone at a location where staff or volunteers may be
endangered. This includes physical, verbal or substance abuse by a client or anyone in the client’s household or
building, or for any other reason determined by Community Servings. Failure to abide by this guideline can
result in the suspension of meal deliveries for up to 90 days, or the cancellation of clients’ meal delivery service.
Client
Authori
z
ation
for
Rele
as
e
of
Information
I, , have requested services from Community Se1vings. I
unders
ta
nd
th
at
in
order to provide se1vices, Community Seivings
ma
y need
to
release/
and
or
receive information
about
me
to/ from:
(Please
lis
t the n am
es,
p h on e n u
mb
ers
and
a
ddr
esses
of
th
e
agenc
i
es
/ p
ersons
th at
we
ma
y
nee
d
to
con
t
ac
t)
Name
of
Contact
Name
of
Agenc
y &
Ad
d
ress
Te
lep
hone
My
Primary
Ca
re
Phy
sici
an
1.
My Medical
Case
Manager
or
So
ci
al Worker
2.
My
Care
taker
3.
A dd
it
iona
l
conta
ct
(if
ne
c
essa
ry)
4.
A dd
it
iona
l
conta
ct
(if n
ec
essary
)
5.
I understand
and
agree
th
at Community Se1vings
ma
y disclose information
about
my
ph
ysical, medical,
psychological, financial
and
legal circumstances.
I grant this authorization
on
the condition that Community Se1vings will use due care
at
all times to protect my
rights
to
privacy
and
confidentia
li
ty. I understand that I
ma
y revoke this authorization
in
writing
at
an
y time except
to
die extent that Community Seivings has already disclosed information based
on
this agreement.
Furdiermore, unless specifically
st
ated, this release form will be
good
for one year from
die
date it is signed.
Date:
------------
Conu
nunity
S
erving
s - 179 Amory Street- Jamaica Plain,
MA
02130- T
el.
617-522-7777 - Fax 617-
522-
777
0
Revised
: June 2
019
Page 1
ofl
Please sign, date and return to Client Services
Comm
unity Servings – 179 Amory Street- Jamaica Plain, MA 02130- Tel. 617-522-7777 - Fax 617-522-7770 Revised: June 2019
Page 1 of 1
Client Agreement
I have read an
d agree with the Client Responsibilities, Rights and Grievance Procedure.
I have read and accept the Missed Meal Delivery Policy.
I have read and agree with the Client Acknowledgements.
I understand this authorization will have duration of
one
year from the date of my signature.
I understand all Community Servings guidelines and have received a client copy of this document.
__________________________________ __________________________________
Client’s Signature Date
To be completed by HIV/AIDS and Hep C applicants only
I,
__________________________________, authorize the staff of Community Servings to allow the Ryan
White Part A or Massachusetts Department of Public Health Grantee or their designee access to and review of my
client record. The purposes of review are for monitoring only. The review may include information such as name,
HIV status and related diagnosis, substance abuse treatment, medical care and treatment, financial circumstances,
living arrangements, and other information as requested. I understand that the review will be visual only and that
no records will be copied and no information identifying me will be recorded.
The authorization for release of information is for visual review only and in no way authorizes the Ryan White Part
A or Massachusetts Department of Health Grantee or their designee the right to remove information or collect
personal identifiers, except in cases of suspected fraud or other criminal wrongdoing.
The authorization does not disclose any information of a personal and confidential nature to any employee or
volunteer who is not authorized with my consent.
This authorization will have a duration of one year from the date signed below. I understand I am not required by
law to consent to release this information, but choose to do so willingly and voluntarily. I understand I may revoke
consent at any time except to the extent action has been taken in reliance of my consent.
______________________________ ________________________
Client’s Signature Date
Six-Month Eligibility Recertification Summary
Form only to be completed for applicants with HIV/AIDS or Mono-Infected Hepatitis C
The
p
urpose of this form is to document the ongoing components of eligibility: financial, residential and
insurance coverage for individuals receiving Ryan White Part A services. This form can be shared among
service providers to verify, income, residency and health insurance coverage if the client has signed and
dated a release of information document. This form is valid for 6 months after screening date.
Client Name:
Client Code:
Screening Date:
Expiration date (six month after screening):
Income
Client Annual Income
% of Federal Poverty Level
o Pay Stubs (2 most recent)
o Social Security (SSDI/SSI) Letter
o Private Disability Statement
o Masshealth Verification Form
o Department of Transitional Assistance
(TANF/EAEDC)Letter
o Veterans’ Benefits
o Medical Case Manager Letter
o Client Affidavit
o Other:______________
Residency
o Pay Stub
o Government Issued Check
o Government Correspondence
o Valid Driver’s License/MA ID
o Utility Bill
o Bank Statement
o Real Estate Tax Bill
o Current Residential Lease
o Medical Case Manager Letter including
town and zip code
o Other______________________
Insurance
o HDAP Approval Letter
o Letter from Insurer
o Premium Statement
o Dated Print out from Exchange
o Mass Health Approval Letter
o Other:______________
I, ___________________________, currently am receiving Ryan White Part A services from
Community Servings. In the last six months, there have been no changes to my eligibility for Part A
services. I understand that I must report any changes to my income, residency, and insurance to
remain eligible to receive these services.
Client Signature _________________________________________________
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Community Servings Home Delivered Meals Program

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Completed 3 November 2020

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