Determine Eligibility

OTC+ Grocery+ Home Delivered Meals Eligibility Form

Please confirm any medical conditions that apply. Select all that apply.

Chronic alcohol and other substance use disorders (SUDs), including but not limited to:

Substance abuse (alcohol, opioid/drug abuse)Tobacco use and related conditions

Autoimmune disorders, including but not limited to:

Polyarteritis nodosaPolymyalgia rheumaticaPolymyositisSystemic lupus erythematosus

Cancer, including but not limited to:

CancerHodgkin lymphomaLeukemia

Chronic gastrointestinal disease, including but not limited to:

Chronic lung disorders, including but not limited to:

Chronic mental health conditions, including but not limited to:

Neurologic disorders, including but not limited to:

Amyotrophic lateral sclerosis (ALS)EpilepsyExtensive paralysis (e.g., hemiplegia, quadriplegia, paraplegia, monoplegia)History of strokePolyneuropathyPost-organ transplantationSpinal stenosisStroke-related neurologic deficit

Immunodeficiency and immunosuppressive disorders, including but not limited to:

Chronic granulomatous disease (CGD)Common variable immunodeficiency (CVID)Complement deficienciesDiGeorge syndromeSevere combined immunodeficiency (SCID)Wiskott-Aldrich syndromeX-linked agammaglobulinemia (XLA)

Conditions with functional challenges, including but not limited to:

No condition(s) above

Provider Attestation (all mandatory fields)

I certify that I am the member’s primary care provider (PCP), specialist or other healthcare provider and that the information provided is accurate to the best of my clinical knowledge.

This attestation applies to the named Elderplan Member for one of the named conditions above in contract year 2027.

Healthcare Provider Full Name

Registry

Individual Identification Number
Exactly 10 characters.