CalAIM Community Supports Inquiry Form

Please select member’s chronic condition Select an option Diabetes - Type I Diabetes - Type II Gestational Diabetes Hyperlipidemia Hypertension Stroke Congestive Heart Failure Chronic Kidney Disease Mental/Behavioral Health Conditions Other

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Medi-Cal Member and Health Plan Information

At this time your insurance company doesn't offer medically tailored meals.

Preferred Language* If other, please specify

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Please indicate which of the following best describes the member and their need for medically tailored meals (select all that apply) *

1. Meals will help me to follow dietary guidelines for my chronic condition.

2. Meals will help to reduce stress or anxiety because I don't have to shop and cook.

3. Meals will allow me to eat regularly or not skip meals which improves my quality of life.

4. Meals will help me have time to focus on other aspects of my self-care like going to my doctor's appointments and taking my medication.

5. Meals are helping to improve my condition and I want to continue to improve.

6. Meals will help me to stay out of the Emergency Room or hospital.

7. My doctor recommended that I eat a special diet and Mom's Meals will help me to follow that diet.

8. My doctor told me to stay on these meals.

9. I have a hard time shopping and cooking for myself.

10. Due to my health and living circumstances home delivered meals are my only option for nutrition.

11. None of these apply to me.

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Please indicate if the Medi-Cal member has any food allergies

If the allergen is contained anywhere in the meal kit, the meal will not be available.

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Care Manager/Social worker Information

Do you have a care manager or social worker assigned to assist with your care needs? Select Option Yes No

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