Spreadsheet: 1b07d525-d787-43a4-a9e9-8c065227f60f
Sheet: Sheet1

Referral for ASF Nutrition and Transportation Services | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Fax to (949) 809-5779
Date: |  |  |  |  |  |  |  |  |  | ARIES ID # |  |  |  |  |  |  |  |  |  |  |  | (Revised 4/17/14)
Client Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]:
 |  |  |  | First |  |  |  | MI or |  |  |  |  | Last
Residence:
 |  |  |  |  |  | Street Address |  |  |  |  |  |  |  |  | City |  |  |  |  |  | Zip Code
Referring Agency: |  |  |  |  |  |  |  | Staff Member: |  |  |  |  |  |  |  |  |  |  | Staff Phone:
Signature of Referring Staff Member:
Date of Birth: |  |  |  |  |  |  |  |  | Hispanic: |  |  | Yes |  | No |  | Unknown
Gender: |  |  |  |  |  |  |  |  | Race:
 | Male |  |  | Transgender M2F |  |  |  |  |  | White |  |  | Pacific Islander |  |  |  |  | Unreported/Unknown
 | Female |  |  | Transgender F2M |  |  |  |  |  | Black |  |  | Asian |  |  |  |  | Other:
 | Other |  |  | Refused to report |  |  |  |  |  | American Indian or Native Alaskan
 | [NAME] eligibility screening has been completed.
 |  | Date of completed eligibility screening: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Expiration date:
 | or |  | Eligibiliy screening not complete. |  |  |  |  |  |  | 30-day Grace Period Start Date (or N/A):
 | Client been informed of the Client Rights and Responsibilities and the Client Grievance Process.
 | Client has signed a current ARIES Consent Form.
o | I, as the person making this referral, have a completed [NAME] and Eligibility Form (EVF) or equivalent agency's form (fax with Referral).
 |  | ARIES Form is Shared and is valid from |  |  |  |  |  |  |  |  |  |  |  |  | to
 | or |  | ARIES Form is Non-Shared and is valid from |  |  |  |  |  |  |  |  |  |  |  |  |  | to
 |  | F | Fax ARIES Form with bottom section filled out giving ASF permission to share client's info with ARIES
F | Fax signed ASF Notice of Privacy Practices (HIPAA) (Initial referral only)
F | Fax Release of Information indicating PHI can be shared between referring agency & ASF (Initial referral & as updated)
Mthly Household Income: |  |  |  |  |  |  |  | Source(s) |  |  |  |  |  |  |  | Household #: |  |  | Head of Household
 | Nutrition Services
 |  | Client is permanently disabled.   Date of permanent disability:
 | or |  | Client is temporarily disabled.
 |  |  | Date of disability: |  |  |  |  |  |  |  |  |  | Date of reevaluation:
 |  | Food Pantry - Client does not have suffient food resources (i.e. [NAME], WIC, board and care).
 | o | Client has provided a signed Physician’s Verification of HIV Disease (VOD) indicating disability (fax with Referral)
 | or |  | Mini Pantry is requested.  Client receives home-delivered meals but needs additional food.
 |  | Nutritional Supplements - Clients cannot receive supplements through medical insurance.
 | o | Client is authorized to receive _________ units of nutritional supplements each month for  ________ months
 | o | A nutritional assessment of the client has been completed and signed by a Registered Dietitian or
 |  | Registered Nurse, or the client has provided a prescription signed by a physician (fax with Referral)
 | o | Client has provided a signed Physician’s Verification of HIV Disease indicating disability (fax with Referral)
 | F | Fax Physician's Recommendation for Nutritional Supplements or nutritional assessment by RD or Nurse CM.
 | Medical Transportation
 |  | Client does not have other means of transportation (i.e. car, friends, family, caregiver).
 |  | Client has been assessed in the past 6 months for appropriateness of transportation requested.
 |  | Bus passes are requested. |  |  |  |  |  | or |  |  | ACCESS fare coupons are requested.
 |  | Please contact ASF's Transportation Department for a Bus Pass/ACCESS Fare Coupon Request form.
 | F | Fax copy of proper ID for reduced fare bus pass or ACCESS approval letter (Initial referral)
 |  | Fax or email Bus Pass/ACCESS Fare Coupon Request Form at least 1 week prior to first appointment.
 |  | Van rides requested for medical, dental or mental health appointment.
 |  | Contact ASF's Transportation Supervisor for arrangements at least 2 business days prior to appointment.
Date Received by ASF: |  |  |  |  |  |  |  |  |  | Notes: