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Secure application
HIPAA Secure

Request Your Free Food Benefits

Your privacy is our priority. This form is encrypted and securely processed in strict accordance with HIPAA health privacy laws to verify your Medicaid coverage.

Fresh Meals

Free fresh meals delivered to your home.

Complete the application in two quick steps. Built for your tablet, simple for every client.

Step 1 Personal details
Step 2 Medicaid & health
Start with the member's contact and delivery information.
1

Personal Details

Used to confirm identity and age-based program guidelines.
2

Contact & Delivery Information

Optional: tap Verify to look up the address and fill in ZIP & borough automatically.
Finish with insurance, health details, and any notes for the team.
3

Insurance Information

This is the 8-character ID found on your blue/white NY Medicaid card or your Managed Care plan card (e.g., AA12345X).
4

Health Profile

5

Which benefits are you interested in?

6

Preferred Language

7

Additional Notes (Optional)

8

Attestation & Consent

Type your full legal name. This serves as your electronic signature.

By submitting you agree to be contacted about your benefits. No cost, no obligation. Your information is transmitted encrypted and is never sold or shared for marketing.

✓

Application received!

Thanks, friend - your application was submitted securely. A specialist will call you shortly to confirm your food benefits.

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