Western Health Advantage Medicare Home Delivered Meal Referral 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.

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.

• 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.

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.

• 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.