Medicaid Meal Support Program

Prenatal & Postpartum Support for mothers and families

Application Form

All information collected through this form is securely stored and maintained in full compliance with HIPAA regulations.

Protected health information is used only for program enrollment and service coordination and is handled according to applicable federal and state privacy requirements.

Personal Information

Please begin with the eligible individual (typically the mother in cases of pregnancy or postpartum).

Please enter your first name.
Please enter your last name.
Please enter your date of birth.

Contact Information

Please enter a valid phone number.
Please enter a valid cell phone number.
Please enter a valid email address.

Address Information

Please enter your street address.
Please enter your city.
Please select your state.
Please enter a valid 5-digit zip code.

Eligibility Screening

Consent, services you need, and questions about your living situation, utilities, food security, and home conditions.

Please select an option.

Select only the services that are most important to you right now. Honest responses help us prioritize requests fairly and serve more families effectively.

Please select at least one option.
Please select an option.
Please select an option.

Note: If you answer Never true you will not get approved for our services, pls answer truthfully.

Please select at least one option.

Eligibility

Note: This program is for Medicaid recipients only.

Please select an option.
Please select an option.

Enter date as mm/dd/yyyy or use the calendar to select.

Please enter the due date or postpartum date.
Please select an option.
Please select an option.
Please select an option.
Please select an option.
Please select an option.
Please select an option.
Please select an option.

Note: Answering “Yes” means you do not qualify for refrigerator/appliance assistance.

Please select an option.

Note: If you answer yes you will not get approved for our services, pls answer truthfully.

Examples: Meals on Wheels, home-delivered meals for seniors, or other food assistance programs offered by NYS.

Please select an option.
Please select an option.
Please select an option.
Please enter your monthly SNAP benefit amount.

Please use the space below to include any relevant information or comments you wish to add.

Household & Family Members

For each child you select, you will be asked for their first name and date of birth.

Please enter how many people live in your household (including yourself).

Nutrition Assessment Form

Please enter a valid email address.
Please enter your full name.
Please enter your age.
Please enter your date of birth as MM/DD/YYYY.
Please select an option.
Please select an option.
Please enter a valid phone number.
Please enter your primary address.
Please enter household size.
Please enter an emergency contact name.
Please enter the relationship.
Please enter a valid phone number.

Share any health or food needs and why meals would be helpful. You may select a statement below to insert standard language, then edit if needed.

Please describe your primary health and nutrition concerns.

HEALTH & MEDICAL HISTORY

Check all that apply: *
Please describe the other condition.

FAMILY HISTORY:

Have any of your close relatives (parent, sibling, child, grandparent) been diagnosed with the following?

Please check, describe, and provide age of onset for those that apply.

Please add details for the family history conditions you selected.
Please select an option.
Please list your medications with dosage, frequency, and start date.
Please select an option.
Please list your supplements with dosage, frequency, and start date.

HEALTH MEASUREMENTS

Please enter your height.
Please enter your current weight.
Please enter your weight from 1 year ago.
Please select an option.
Please select an option.
Please describe your concern.

LIFESTYLE

Please select an option.
Please list the type(s) of exercise or activity.
Please describe how often and how long.
Please select an option.
Please select an option.
Please select an option.

If yes, please specify:

Please enter packs per day (or N/A if not applicable).
Please enter number of years (or N/A).
Please select an option.
Please check any concerns that apply to you.
Please describe the other concern.

FOOD AND DIETARY HABITS:

Please select an option.
Please describe your special diet or program.
Please select an option.
Please explain your adverse food reactions.
Please select an option.
Please describe the foods you dislike or avoid.
Please select an option.
Please enter the grocery shopper’s name.

DAILY DIETARY INTAKE

Please describe your usual breakfast foods.
Please describe your usual lunch foods.
Please describe your usual dinner foods.
Please describe snack foods.
Please list vegetables you eat daily.
Please list fruits you eat daily.
What types of protein do you consume most days of the week? (Check all that apply): *
Please select an option.
Please describe which dairy you eat daily.
What types of grains or grain products do you consume most days of the week? (Check all that apply) *
Please describe the other grain product.

Birthing People ONLY

Please select an option.

If yes

Please enter how many weeks pregnant.
Please enter your expected due date.
Please select an option.
Please select an option.
Please explain the issues.
Please select an option.
Please describe what you drink.
Please select an option.
Please describe what you drink and how often.
Please describe what and how much you drink daily.
Please share any additional information or type N/A if none.

NUTRITION SIGNATURE (for staff use only – please do not fill out)

This section is for staff use only. Applicants should leave these fields blank unless instructed otherwise.

Frequently Asked Questions

This program is for Medicaid recipients who:

  • Do not pay monthly fees for their Medicaid insurance
  • Are on a managed care plan.
  • Are pregnant or have a baby under one year old
  • Have someone in your household with a severe and/or chronic illness, Alzheimer's, renal failure, COPD, HIV/AIDS, mental health condition, substance use challenge or other serious condition
  • Reside in Brooklyn, Queens, Bronx. We're working on Staten Island details to follow

Note: To be eligible, Medicaid recipients must be enrolled in a Managed Care Plan. Child Health Plus, Essential plan, Straight Medicaid members do not qualify.

Eligible families receive 3 nutritious meals per day, 7 days a week for each approved household member through prepared ready meals, delivered twice a week and fully cooked for your convenience. All meals are prepared by trusted kosher caterers:
Chicken – KJ Hashgacha | Meat – Solomon’s Beef | All other products – Cholov Yisroel & Pas Yisroel

Deliveries come twice a week: Monday evening delivery between 7-10 p.m. covers Tuesday - Thursday, and Thursday evening delivery between 7-10 p.m. covers Friday - Sunday and includes Shabbos food.

Delivery is expected to begin within a short time after approval. Your coordinator will give you exact timing once enrollment is complete.

Aim V’yeled Meals

Phone: [Client to provide]
Email: [Client to provide]

We're here to help! Contact us with any questions about the application or program.

Need Help?

If you need assistance completing this form, please contact us at [phone number]