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https://www.magickitchen.com/meal-delivery/MN-referral-form.html
Submission: On January 17 via manual from US — Scanned from DE
Submission: On January 17 via manual from US — Scanned from DE
Form analysis 5 forms found in the DOM
/cgi/user.cgi
<form action="/cgi/user.cgi">
<input type="hidden" name="cmd" value="login">
<div class="form-group">
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<div class="form-group">
<input type="password" class="form-control" id="loginPassword" name="password" placeholder="Enter password">
<label for="loginPassword">Password</label>
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<button type="submit" class="btn btn-default">Log in</button>
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<form method="GET" accept-charset="UTF-8" class="general_product_search_mobile" action="/cgi/search.cgi"> <!-- MOBILE SEARCH BOX -->
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<form method="GET" accept-charset="UTF-8" class="general_product_search" action="/cgi/search.cgi"> <!-- DESKTOP SEARCH BOX -->
<input name="cmd" value="general_product_search" type="hidden">
<input type="hidden" name="report_type" value="serps">
<input type="text" class="form-control" name="text_search" placeholder="What meal are you looking for?">
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<div class="col-xs-12 col-sm-12">
<div class="form-group row">
<div class="col-sm-4"> <label for="Today's Date" class="col-form-label">Today's Date</label>
<input name="Today's Date" type="date" id="today-date" class="form-control" placeholder="Today's Date">
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<div class="col-sm-4"> <label for="Meal Benefit Start Date" class="col-form-label">Meal Benefit Start Date</label>
<input name="Meal Benefit Start Date" type="date" id="meal-benefit-start-date" class="form-control" placeholder="Meal Benefit Start Date">
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<div class="col-sm-4">
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<div class="col-sm-4"><label for="Member’s Insurance" class="col-form-label">Member’s Insurance</label>
<input name="Member’s Insurance" type="text" id="members-insurance" class="form-control" placeholder="Member’s Insurance">
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<div class="col-sm-4"><label for="Authorization Number" class="col-form-label">Authorization Number</label>
<input name="Authorization Number" type="text" id="authorization-number" class="form-control" placeholder="Authorization Number">
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<div class="col-sm-4">
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<div class="col-xs-12 col-sm-12">
<div class="form-group row">
<div class="col-xs-12 col-sm-12"><label for="Provider Making Meal Referral" class="col-form-label">
<strong>Provider Making Meal Referral - Check One</strong></label>
<div class="checkbox">
<div class="col-xs-12 col-sm-2">
<input name="Provider" type="radio" value="State of MN"> State of MN
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<div class="col-xs-12 col-sm-2">
<input name="Provider" type="radio" value="UCare"> UCare
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<div class="col-xs-12 col-sm-2">
<input name="Provider" type="radio" value="Bridgeview"> Bridgeview
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<div class="col-xs-12 col-sm-2">
<input name="Provider" type="radio" value="Medica"> Medica
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<div class="col-xs-12 col-sm-2">
<input name="Provider" type="radio" value="Other"> Other
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<div class="col-xs-12 col-sm-12">
<hr style="padding-bottom:10px;">
<div class="form-group row">
<p><strong>Case Manager/Care Coordinator:</strong></p>
<div class="col-sm-4"><label for="Case Manager/Care Coordinator Name" class="col-form-label">Name</label>
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<div class="col-sm-4"><label for="Case Manager/Care Coordinator Email" class="col-form-label">Email</label>
<input name="Case Manager/Care Coordinator Emails" type="email" id="coordinator-email" class="form-control" placeholder="Case Manager/Care Coordinator Email">
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<div class="col-xs-12 col-sm-12">
<hr style="padding-bottom:10px;">
<div class="form-group row">
<p><strong>Person Receiving Meals:</strong></p>
<div class="col-sm-4"><label for="Person Receiving Meals Name" class="col-form-label">Name</label>
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<div class="col-xs-12 col-sm-12">
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<div class="col-sm-3"><label for="State" class="col-form-label">State</label>
<input name="State" type="text" id="State" class="form-control" placeholder="State">
</div>
<div class="col-sm-3"><label for="Zip" class="col-form-label">Zip</label>
<input name="Zip" type="text" id="zip" class="form-control" placeholder="Zip">
</div>
</div>
</div>
<div class="col-xs-12 col-sm-12">
<div class="form-group row">
<p><strong>Secondary Contact (if recipient unreachable)</strong>:</p>
<div class="col-sm-3"> <label for="Secondary person Relationship to Recipient" class="col-form-label">Relationship to Recipient</label>
<input name="Secondary person Relationship to Recipient" type="text" id="secondary-relationship" class="form-control" placeholder="Relationship to Recipient">
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<div class="col-sm-3"> <label for="Secondary Person's Name" class="col-form-label">Name</label>
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<div class="col-sm-3">
<label for="Secondary Person's Phone" class="col-form-label">Phone</label>
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<div class="col-sm-3">
<label for="Secondary Person's Email" class="col-form-label">Email</label>
<input name="Secondary Person's Email" type="email" id="secondary-email" class="form-control" placeholder="Secondary Person's Email">
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</div>
</div>
<div class="col-xs-12 col-sm-12">
<hr style="padding-bottom:10px;">
<div class="form-group row">
<div class="col-sm-4"> <label for="Number of Meals Approved" class="col-form-label">Number of Meals Approved</label>
<input name="Number of Meals Approved" type="text" id="number-of-meals" class="form-control" placeholder="Number of Meals Approved">
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<div class="col-sm-4"> <label for="Authorization Start Date" class="col-form-label">Authorization Start Date</label>
<input name="Authorization Start Date" type="date" id="authorization-start-date" class="form-control" placeholder="Authorization Start Date">
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<div class="col-sm-4">
<label for="End Date" class="col-form-label">End Date</label>
<input name="End Date" type="date" id="end-date" class="form-control" placeholder="End Date">
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</div>
</div>
<div class="col-xs-12 col-sm-12">
<div class="form-group row">
<div class="radio"><label for="diet choice"><strong>Choose Your Diet Restriction</strong></label>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="General Wellness">
<strong>General Wellness</strong> - (Meets ⅓ Dietary Reference Intake, Dietary Guidelines)
</div>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="Low Sodium">
<strong>Low Sodium</strong>- ‹700 mg/meal, although most are ‹500 mg/meal
</div>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="Diabetic">
<strong>Diabetic Diet</strong>- ‹700 mg/meal, ‹ 65g carbs, although most are 20-45g carbs
</div>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="Renal Diet">
<strong>Renal Diet (CKD Stage 3&4)</strong>- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus, ‹25g protein
</div>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="Dialysis Friendly">
<strong>Dialysis Friendly</strong>- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus
</div>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="Gluten Free">
<strong>Gluten Free</strong>- based on ingredient list, not a dedicated kitchen
</div>
<div class="col-xs-12 col-sm-12">
<input name="Diet Restriction" type="radio" value="Vegetarian">
<strong>Vegetarian Meals</strong>
</div>
</div>
</div>
</div>
<div class="form-group row">
<div class="col-xs-12 col-sm-12"><label for="Allergens" class="col-form-label">
<strong>Check Any Known Allergens</strong></label>
<div class="checkbox">
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Milk"> Milk
</div>
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Fish"> Fish
</div>
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Shellfish"> Shellfish
</div>
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Tree Nuts"> Tree Nuts
</div>
</div>
</div>
<div class="form-group row">
<div class="col-xs-12 col-sm-12">
<div class="checkbox">
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Eggs"> Eggs
</div>
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Peanuts"> Peanuts
</div>
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Soy"> Soy
</div>
<div class="col-xs-12 col-sm-3">
<input name="Allergens" type="checkbox" value="Wheat"> Wheat
</div>
</div>
</div>
</div>
<div class="form-group row">
<div class="col-xs-12 col-sm-12">
<p> </p>
<label for="Special Instructions"><strong>Specialized Meal Plan/ Menu Comments/ Special Delivery Instructions</strong></label><br>
<textarea name="Special Instructions" type="text" rows="4" cols="50"></textarea>
</div>
</div>
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<div class="form-group row">
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</div><br>
<input type="submit" value="Send">
<input name="reset" type="reset" value="Reset">
</div>
</div>
</div>
</div>
</div>
</div>
</form>POST https://enews.magickitchen.com/q/85Zja-SI1jJV85KgF6ORlDkuzF-sKORvnT
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<input type="text" class="form-control" maxlength="100" style="margin-top: 10px" name="email" placeholder="Enter your email">
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<span class="input-group-btn" style="vertical-align: bottom">
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<span class="button-text">Subscribe</span><span class="glyphicon glyphicon-menu-right" aria-hidden="true"></span>
</button>
</span>
</div>
<!-- /input-group -->
</form>Text Content
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yummy Basil Chicken with Rice & Zucchini Saute - 2 svgs
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MINNESOTA LTSS HOME-DELIVERED MEAL SERVICE REFERRAL FORM
MAGIC KITCHEN, INC NPI: 1023363983
Fill out the form below and one of our customer service team will contact you.
Today's Date
Meal Benefit Start Date
Diagnosis/ICD-10 Code
Member’s ID Number
Member’s Insurance
Authorization Number
Provider Making Meal Referral - Check One
State of MN
UCare
Bridgeview
Medica
Other
--------------------------------------------------------------------------------
Case Manager/Care Coordinator:
Name
Email
Phone
--------------------------------------------------------------------------------
Person Receiving Meals:
Name
Date of Birth
Address
Phone
City
State
Zip
Secondary Contact (if recipient unreachable):
Relationship to Recipient
Name
Phone
Email
--------------------------------------------------------------------------------
Number of Meals Approved
Authorization Start Date
End Date
Choose Your Diet Restriction
General Wellness - (Meets ⅓ Dietary Reference Intake, Dietary Guidelines)
Low Sodium- ‹700 mg/meal, although most are ‹500 mg/meal
Diabetic Diet- ‹700 mg/meal, ‹ 65g carbs, although most are 20-45g carbs
Renal Diet (CKD Stage 3&4)- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus,
‹25g protein
Dialysis Friendly- ‹700 mg sodium, ‹700mg Potassium, ‹350mg Phosphorus
Gluten Free- based on ingredient list, not a dedicated kitchen
Vegetarian Meals
Check Any Known Allergens
Milk
Fish
Shellfish
Tree Nuts
Eggs
Peanuts
Soy
Wheat
Specialized Meal Plan/ Menu Comments/ Special Delivery Instructions
For Questions, you can call our Intake Team at 1-800-766-1765.
Hours of Operation: 7AM-6PM CST Menus can be viewed and orders can be placed at
mkmeals.com
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