Gemspire – Intake Form

I hereby provide my consent to be referred to HRSN services I hereby decline referral to HRSN services and understand that by declining.

Select only the services that are most important to you right now. Honest responses help us prioritize requests fairly and serve more families effectively. (You can only choose one of Ready Made Meals or Grocery Boxes; Appliance Support can be added to either.)

Ready Made Meals Grocery Boxes Appliance Support None of the above

Note: If you answer "Never True" you will not get approved for our services, please answer truthfully.

Medicaid ID #

The ID consists of 2 letters, followed by 5 numbers, and ending with another letter. You can find this on your Medicaid or insurance card.

Household Members with Medicaid

Enter the number of household members who have Medicaid. Medicaid ID fields will appear for each member.

Enrolled in Health Home Care Management Pregnant Had a miscarriage Postpartum (within the last 12 months) Substance Use Disorder diagnosis Serious Mental Illness diagnosis Child under the age of 18 diagnosed with a chronic condition Other

I attest that the information I provided is accurate and complete to the best of my knowledge. I do not attest that the information I provided is accurate and complete.

Note: If you answer "Yes," you may be eligible to receive grocery boxes. If you answer "No," you may be eligible to receive ready-made meals. Please answer truthfully.

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

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

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