Answer what you can — no field is required, and we will follow up if we need anything else.
About you Last name
Date of birth
Preferred language English Spanish Mandarin Cantonese Vietnamese Tagalog Korean Russian Arabic Armenian Farsi Khmer Hmong Punjabi Other
Gender Choose one Female Male Unknown
Do you have Medicaid? Yes No Not sure
NY Medicaid health plan The New York Medicaid managed care plan on your card (Healthfirst, Fidelis, MetroPlus, and other Bronx / NYC plans). Choose Other if you are not sure, or Fee-for-service if you do not have a managed care plan.
Choose one Healthfirst Fidelis Care MetroPlus Health Plan EmblemHealth Anthem / Empire BlueCross BlueShield HealthPlus UnitedHealthcare Community Plan Molina Healthcare Affinity by Molina Wellcare of New York SOMOS Community Care VNS Health CHOICE Centers Plan for Healthy Living Elderplan VillageCareMAX Fee-for-service (no managed care plan) Other / not listed How to reach you Text messages (optional)
Optional: check this box to receive informational text messages and calls from Medicaid Meals (Vista Verde Homes) at the phone number provided, using automated and artificial voice technology, about your eligibility screening, referrals, application status, and available services. Consent is not a condition of service. You can submit this form without checking it. Consent is not required to submit this form or to receive services.
Optional: check this box to receive text messages and calls about my screening, referrals, application status, and available services. (optional) SMS consent is optional. You can leave this box unchecked and still submit this form and get help; we will reach you by email instead, or you can email info@medicaidmeals.org. Consent is not a condition of service. These are informational messages, not marketing. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Privacy Policy and Terms and Conditions .
Another phone number (optional)
Email
I do not have an email address
Your consent The referral authorization below is needed to send your answers. Agreeing to text messages, calls, or email is optional. Consent to text messages is not a condition of service.
I authorize Vista Verde Homes (Medicaid Meals) to use the information I provide, including my Medicaid Client ID, to identify programs I may qualify for and to share my information with Medicaid Managed Care Plans, Social Care Networks, and authorized service providers for eligibility review and referral purposes. I understand that participation is voluntary, I may withdraw at any time, and completing this form does not guarantee eligibility or services.
By submitting this form, you confirm that the information you provide is accurate to the best of your knowledge. You authorize Vista Verde Homes to use your responses to evaluate potential program eligibility. You consent to the limited sharing of your contact and qualification information with appropriate government, nonprofit, or community-based service providers for the purpose of facilitating referrals. You understand that participation is voluntary and that you may decline or withdraw from the referral process at any time. You acknowledge that Vista Verde Homes is not a healthcare provider, insurer, or government agency and does not guarantee acceptance into any program. I agree to the eligibility screening and referral authorization above.
You agree to receive emails about your eligibility screening, referrals, and application status. You can unsubscribe at any time.
I agree to receive emails about my screening and referrals. (optional)
Participation is voluntary. You can withdraw at any time. Completing this form does not guarantee eligibility or services.
Text messages are optional. Consent is not a condition of service. You can send this form without checking the text-message box.
