FOR OFFICE USE ONLY

Date of Application ____/____/____

Beginning Date ____/____/____

Route Number __________

M.P. __________   Diet/Bev. __________

 REFERRAL

Referred by ___________________________________

Agency/Name _________________________________

Phone _______________________________________

FAX _________________________________________


RECIPIENT INFORMATION

Name___________________________________________ Sex______________________________

Address___________________________________________________________________________
               Street                                 (Apt.#)                                                            City                                         Zip

County__________________ Phone_____________________ Date of Birth_____________________

Race___________________________                Social Security Number ________-______-__________


EMERGENCY CONTACT

1. Relative________________________________________ Relationship_______________________

Address___________________________________________________________________________
               Street                                 (Apt.#)                                                            City                                         Zip

Phone (H)__________________________________ (W)_____________________________________

2. Friend/Relative______________________________________ Relationship____________________

Address____________________________________________________________________________
               Street                                 (Apt.#)                                                            City                                         Zip

Phone (H)______________________________________ (W)__________________________________


MEAL SERVICE INFORMATION

1. DAYS MEALS NEEDED (check each)
_____MON _____TUES _____WED _____THURS _____FRI

2. DIET NEEDED (All diets are no-salt-added)
_____General _____Diabetic _____Renal _____Vegetarian _____Chopped Meat _____Pureed

3. FOOD ALLERGIES__________________________________________________________________

DISABILITY		  
MOBILITY		  
HOME HEALTH SERVICES
_____Speech _____on Oxygen
 _____Ambulatory _____Bedridden Do you currently receive?  Yes / No
_____Hearing _____Visual _____Cane/Walker _____Wheelchair Name of Agency______________
        Days/Week_____ Hrs./Day_____

CURRENT MEAL SERVICES (check all that apply)
___Daily Bread
___Church
___Other
Days Week _____

LIVING ARRANGEMENT
HOUSING ARRANGEMENT
TRANSPORTATION
_____Alone _____Home (Own or Rent?) Do you drive?  Yes / No
_____with Relatives _____Apartment Use a van service / area bus
_____Other _____Other Depend on family / friends


PHYSICIAN INFORMATION

Physician name_____________________________________________ Phone______________________

Address______________________________________________________________________________
               Street                                 (Apt.#)                                                            City                                         Zip

Hospital Preferred______________________________________________________________________


FEE INFORMATION

There is a fee for meals, but your ability to pay determines the price. The actual cost of meal is $4.75 per day.  Do you need a fee adjustment? _____Yes _____No

FINANCIAL INFORMATION      If you need a fee adjustment, the following information is REQUIRED.
MONTHLY INCOME $_______________ MONTHLY EXPENSES $_______________
Social Security $_______________ Housing $_______________
Private Pensions $_______________ Utilities $_______________
Veteran $_______________ Medical $_______________
Other $_______________ Other $_______________

Do you receive Food Stamps? _____Yes _____No If so, what amount? $____________per__________


BILLING INFORMATION

Please send monthly bill to:

Name ______________________________________________________________________________
               First                                                                                      Last

Address_____________________________________________________________________________
               Street                                 (Apt.#)                                                            City                                         Zip

Phone (H)___________________________________ (W)_____________________________________

I understand and agree to the following billing procedures:
1. Statements are mailed at the end of the month and payable upon receipt.
2. Regular fees are charged for meals in cancellations are not made by 9 a.m. of the day of service.
3. Fee adjustments may be made at any time during program participation if eligibility is met.

NOTE: Please call (434) 392-8797 for more information.

RELEASE OF INFORMATION: In the event that I am undergoing treatment at a medical or long-term care facility, I authorize communication to that effect between the facility and SCOPE/Meals on Wheels.

___________________________________________________________________________________
Signature of Applicant or Designee


BACK