Kentucky HCB Waiver Referral Form

Please fill in the required information below and click SUBMIT FORM at the bottom of the page.

Mastersons Food and Drink

KYIND Meals Service Referral Form

Mastersons NPI # 7100889880

Todays Date

Month

Day

Year

Diagnosis/ICD-10 Code

Clients Medicaid ID #

Waiver # on Prior Authorization

Case Manager/Care Coordinator Name

Case Manager/Care Coordinator NPI Number

Case Manager/Care Coordinator Email

Case Manager/Care Coordinator Phone #

Referring Physicians Name

Name of Client Receiving Meals

Clients Date of Birth

Delivery Address for Meals (Include apartment or unit # if applicable)

Phone # for Delivery Address

Number of Meals Authorized

The above number is authorized per(Check One)

Week

Month

Meal Type

Lunch/Dinner

Breakfast

Special Modification if Applicable

Mechanical Soft (texture-modified diet for those people who have difficulty chewing or swallowing)

Pureed (for dysphagia patients and those with difficulty swallowing)

Additional Meal Notes or Requirements

Special Delivery Instructions

Questions?

Phone

Jessica Hagan

502-636-2511 Extension 116