COPES Food & Nutrition Services Application

COPES Ancillary Services: Meals & Nutrition Counseling Referral Form

Please complete all required fields and authorization(s) in Provider One (https://www.waproviderone.org/) before submitting this form to avoid delays in processing the application. Our COPES vendor number is 628880. You can refer a client for meals or to meet with a dietitian (nutrition counseling) or BOTH.
COPES allows for 14 or 28 meals per month. The program requires a reduction in 30 minutes of covered caregiving per meal.
- For clients who want 14 meals per month, this is equivalent to 7 hours of caregiving.
- For 28 meals per month, it’s 14 hours.
For six (6) monthly visits with a dietitian for nutrition counseling, no exchange of hours is required: It is effectively “free” to all COPES clients. Most visits are done over the phone, but alternatives are available. We encourage you to refer all COPES clients for nutrition counseling.

Questions? Please email foodservices@Lifelong.org or call (206) 957-1686
Referral Information
I am referring this client for:
Referring Provider Name
Title
Agency/Hospital
Phone
Format: (000) 000-0000.
Extension
Email
example@example.com
ProviderOne Authorization Start Date: Meals

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ProviderOne Authorization End Date: Meals

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ProviderOne Authorization End Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ProviderOne Authorization Start Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many meals does the client want per month?
ProviderOne Authorization Start Date: Nutrition Counseling

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ProviderOne Authorization End Date: Nutrition Counseling

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Information
Client First Name
Client Last Name
Pronouns
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Is the phone a cell phone?
Does the client consent to receiving text messages?
Email (enter only if client consents to receiving email messages)
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:
Gender Identity:

Other
Primary Language
If not English, does this person need an interpreter?
Best time to contact client
Person who prepares food and shops for groceries:

Other
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship to Client
Health Information:

Attach medical diagnoses and medication sections from most recent annual assessment. Please do not attach entire assessment. If you have this information but cannot include as an attachment, you can enter it under "reason to see dietitian" below.
Problem List

Cancelof
Medication List

Cancelof
Height (inches)
Weight (pounds)
Reason for dietitian to see client:
There's no wrong answer. Some common topics include: digestive symptoms (i.e. nausea or constipation), poor appetite, learning to manage health condition (high blood pressure, diabetes, etc.) with diet, meal prep tips or recipe ideas.
Other Comments or Relevant Information:
Referral Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

COPES Ancillary Services: Meals & Nutrition Counseling Referral Form

Referral Information

Client Information

Health Information: