Check your eligibility

Complete this short intake form and our team will review your information and contact you about the appropriate next step. You may qualify — our team will review your information and guide you through the next steps.

Eligibility and meal coverage depend on program requirements, member eligibility, medical/nutritional needs, and authorization.

Eligibility intake form

Fields marked optional can be left blank. The more you share, the faster we can identify the right next step.

Member information

First name

Last name

Date of birth

Phone

Email (optional)

Delivery address

Street address

Apartment, unit, floor (optional)

City

State

ZIP code

Coverage information

Medicaid / member ID

Medicaid health plan

Medical & nutritional information

Medical conditions

Current nutritional needs

Food access / meal preparation needs

Allergies

Dietary restrictions

Referral & contact preference

Referring organization (optional)

Referring professional (optional)

Preferred contact method

Consent

I authorize TriMeals to collect and use the health and contact information I have provided in order to review potential eligibility, coordinate a medically tailored meal plan, and communicate with my health plan or healthcare providers as needed for that purpose. I understand that submitting this form does not guarantee eligibility, approval, coverage, or reimbursement, and that I may withdraw this authorization by contacting TriMeals.

Submission of this form does not guarantee eligibility or approval.