MN Referral Form | MK Meals

Today's Date

Meal Benefit Start Date

Diagnosis/ICD-10 Code

Member’s ID Number

Member’s Insurance

Authorization Number

Provider Making Meal Referral

State of MN

UCare

Bridgeview

Medica

CDCS

Health Partners

Other

Where do we send the bill? (county, company, email, etc)

Case Manager/Care Coordinator:

Name

Phone

Person Receiving Meals:

Name

Date of Birth

Address

Phone

City

State

Zip

Secondary Contact (if recipient unreachable):

Relationship to Recipient

Name

Phone

Number of Meals Approved

Authorization Start Date

End Date

Does this member have a patient responsibilty (Spenddown, Deductible, Co-Pay)? Yes

If so, how much is the patient responsibility?

Choose Your Diet Restriction

General Wellness - (Meets ⅓ Dietary Reference Intake, Dietary Guidelines)

Low Sodium- ‹700 mg/meal, although most are ‹500 mg/meal

Diabetic Diet- ‹700 mg/meal, ‹ 65g carbs, although most are 20-45g carbs

Renal Diet (CKD Stage 3&4)- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus, ‹25g protein

Dialysis Friendly- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus

Gluten Free- based on ingredient list, not a dedicated kitchen

Vegetarian Meals

Check Any Known Allergens

Milk

Fish

Shellfish

Tree Nuts

Eggs

Peanuts

Soy

Wheat

Specialized Meal Plan/ Menu Comments/ Special Delivery Instructions

Member’s Insurance Provider/Payer

Magic Kitchen, INC NPI: 1023363983

Provider Making Meal Referral

Minnesota LTSS Home-Delivered Meal Service Referral Form for MagicKitchen.com

Member’s Insurance Provider/Payer

Magic Kitchen, INC NPI: 1023363983

Provider Making Meal Referral