[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-403409-105":59,"doc-detail-403409-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","medically-tailored-mealsmedically-supportive-food-authorization-form","Medically Tailored Meals/Medically Supportive Food - Authorization Form","","Medically Tailored Meals/Medically Supportive Food authorization form for Medi-Cal members addresses chronic or serious nutrition-sensitive health conditions to improve outcomes and reduce unnecessary medical costs. The service covers up to two meals per day or a weekly grocery box for up to 12 weeks, using evidence-based nutrition guidelines and not intended to address food insecurity. The form collects member, provider, referral, eligibility, required documentation, and includes sections for initial requests, extensions, meal type selection, and health improvement description.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/medically-tailored-mealsmedically-supportive-food-authorization-form/403409/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/medically-tailored-mealsmedically-supportive-food-authorization-form/403409.png","ImageObject",300,407,{"name":92,"@type":93},"Blue Pony","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-27",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",11,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What does the Medically Tailored Meals/Medically Supportive Food program cover and for how long?","Question",{"text":113,"@type":114},"It covers up to two meals per day or a weekly grocery box for up to 12 weeks. Medically tailored meals must follow evidence-based nutrition guidelines for specific nutrition-sensitive health conditions.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What is the difference between medically tailored meals and medically supportive foods?",{"text":118,"@type":114},"Medically tailored meals include either prepared meals or grocery boxes. Medically supportive foods are supplemental and are intended as a step-down intervention from medically tailored foods when appropriate.",{"name":120,"@type":111,"acceptedAnswer":121},"What documents are required for initial authorization versus reauthorization or extensions?",{"text":122,"@type":114},"Initial authorization requires a nutritional assessment and a signed physician order. Reauthorization/extensions require updated versions of those documents plus detailed referral rationale documenting program benefits and improvements.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},403409,1790648776,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":81,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":39,"preview_page_count":4},962090760266,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","MEDICALLY TAILORED MEALS/MEDICALLY SUPPORTIVE FOOD  \nAUTHORIZATION FORM  \nMedically Tailored Meals/Medically Supportive Food addresses members’ chronic or serious nutrition-sensitive health conditions and is intended to improve health outcomes while reducing unnecessary medical costs.  \nThis service covers up to two meals per day, or a weekly grocery box, for up to 12 weeks. Medically tailored meals must adhere to established, evidence-based nutrition guidelines for specific nutrition-sensitive heath conditions and are not intended to respond to food insecurities.  \nFor more information, review the Medically Tailored Meals Authorization Guide.  \nComplete and submit this authorization form with the Medi-Cal – Prior Authorization Request Form –  \nOutpatient either online (recommended) [at](at provider.healthnetcalifornia.com)[ provider.healthnetcalifornia.com](at provider.healthnetcalifornia.com) or by fax at 800-743-1655.  \n\n| ☐ Initial request ☐ Extension request\u003Cbr>☐ Member consented to Medically Tailored Meals/Medically Supportive Food referral. |  |  |\n| --- | --- | --- |\n| Member information |  |  |\n| Member name: |  |  |\n| Medi-Cal ID: | Date of birth: |  |\n| Phone number: | Preferred language: |  |\n| Home address: |  |  |\n| Contact name (if different than member): |  | Relationship: |\n| Phone number: |  | Preferred language: |\n| Member’s height: |  | Member’s weight: |\n| Community Supports provider information (servicing organization) |  |  |\n| Organization name: |  |  |\n| Tax identification (ID): | National Provider Identifier (NPI): |  |\n| Staff name: | Title: |  |\n| Phone number: | Fax number: |  |\n| Referral information (referring entity) |  |  |\n| ☐ Check this box if the referring entity is the same as the Community Supports provider. |  |  |\n| Name: |  |  |\n| Address: | Phone number: |  |\n| Email address: | Fax number: |  |\n\n*Health Net of California, Inc. and Health Net Community Solutions, Inc. are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.  \n26-467b (4/26)  \n| Referral type |  |  |\n| --- | --- | --- |\n| Primary intervention: Initial meal type1 request (select one):\u003Cbr>☐ Medically tailored meals ☐ Medically tailored groceries\u003Cbr>Step-down intervention: Supplemental meal type request:\u003Cbr>☐ Medically tailored groceries ☐ Medically supportive foods2 |  |  |\n| Eligibility criteria |  |  |\n| Member must meet this requirement: Member has nutrition-sensitive health condition(s) |  |  |\n| (select all that apply).\u003Cbr>☐ Cancer(s)\u003Cbr>☐ Cardiovascular disorders\u003Cbr>☐ Chronic kidney disease\u003Cbr>☐ Chronic lung disorders or other pulmonary conditions such as asthma/COPD\u003Cbr>☐ Chronic or disabling mental/ behavioral health disorders\u003Cbr>☐ Diabetes or other metabolic conditions\u003Cbr>☐ Dyslipidemia\u003Cbr>☐ Elevated lead levels | ☐ End-stage renal disease\u003Cbr>☐ Fatty liver\u003Cbr>☐ Gastrointestinal disorders\u003Cbr>☐ Gestational diabetes\u003Cbr>☐ Heart failure\u003Cbr>☐ High cholesterol\u003Cbr>☐ High-risk perinatal conditions\u003Cbr>☐ Human immunodeficiency\u003Cbr>virus ☐ Hypertension ☐ Liver disease | ☐ Malnutrition\u003Cbr>☐ Obesity\u003Cbr>☐ Stroke\u003Cbr>☐ Other, please list:\u003Cbr> |\n| ☐ Member confirmed their nutrition-sensitive condition (check the box for confirmation) |  |  |\n| Required documents for authorization |  |  |\n| Initial authorization: Submit all required documents with the authorization form for new authorization requests (all boxes must be checked):\u003Cbr>☐ Nutritional assessment by registered dietitian or other appropriate clinician. Include the meal plan and standards to meet the dietary needs of the member’s nutrition-sensitive health condition.\u003Cbr>☐ Physician order signed by a licensed healthcare provider or other appropriate clinician, such as a physician, registered dietitian (RD), clinical nurse specialist (CNS), nurse practitioner (NP),\u003Cbr>pharmacist, physician assistant ","cbCailozTP3tL3FR","https://ap.wps.com/l/cbCailozTP3tL3FR","pdf",1457810,"English","# Authorization Form Overview\n## Service coverage and eligibility\n# Member Information\n## Contact and demographics\n# Community Supports Provider Information\n# Referral Information\n## Referral type and interventions\n# Eligibility Criteria\n## Nutrition-sensitive health conditions\n# Required Documents for Authorization\n## Initial and reauthorization/extensions\n# Health Improvement Description\n## Describe outcomes after meals","[{\"question\":\"What does the Medically Tailored Meals/Medically Supportive Food program cover and for how long?\",\"answer\":\"It covers up to two meals per day or a weekly grocery box for up to 12 weeks. Medically tailored meals must follow evidence-based nutrition guidelines for specific nutrition-sensitive health conditions.\"},{\"question\":\"What is the difference between medically tailored meals and medically supportive foods?\",\"answer\":\"Medically tailored meals include either prepared meals or grocery boxes. Medically supportive foods are supplemental and are intended as a step-down intervention from medically tailored foods when appropriate.\"},{\"question\":\"What documents are required for initial authorization versus reauthorization or extensions?\",\"answer\":\"Initial authorization requires a nutritional assessment and a signed physician order. Reauthorization/extensions require updated versions of those documents plus detailed referral rationale documenting program benefits and improvements.\"}]","Medically Tailored Meals/Medically Supportive Food - Authorization Form | PDF",1790540075]