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Our programs are based in the Minneapolis/St. Paul metro area. If you’re looking for a program in another area, visit mealsonwheelsamerica.org.
Street Address*
Apartment Number
City*
State*
Zip Code*
indistrict
This is a HIDDEN field. DO NOT EDIT THIS OR FORM WILL NOT WORK

We deliver to this address!
Would you like to fill out your application online or continue via phone?*
- Continue Online
- Continue Via Phone
Please choose one of the following*
- I am a care professional or agency enrolling a client through a government-funded program
- I am a caregiver, meals are for myself, a loved one, or family member (self-pay)
Are these meals for you?*
- Yes
- No
Requestor Information
As the person completing this form, please tell us a little bit about yourself:
Name*
First Last
Email
Daytime Phone Number*
Address*
Street Address Address Line 2 City State ZIP Code
What is your relationship to the person who will receive meals?*

Meal Recipient Information
Our clients' privacy is important to us. Please take a minute to review our Notice of Privacy Practices before continuing.
Name*
First Middle Initial Last
Daytime Phone Number*
Email
Date of Birth*
MM
DD
YYYY
Metro Meals on Wheels does not discriminate on the basis of gender identity or race. We use gender and race data to track the effectiveness of our program. Your answers to the following questions will not affect your ability to receive services.
Gender*
Race/Ethnicity*
- White
- Black or African American
- Latino or Hispanic
- Asian
- American Indian or Alaska Native
- Native Hawaiian or Other Pacific Islander
- Other
- Prefer not to answer

Billing Information
Meals are priced affordably and based on your ability to pay. We will follow up with you after you submit this form to discuss payment options. Call us at 612-623-3363 with any questions.
Billing address*
- Billing address is my address
- Billing address is the home address of the person receiving meals
- Enter another billing address
Billing address*
- Billing address is my address
- Enter another billing address
Name
First Last
Billing Address*
Street Address Address Line 2 City State ZIP Code
Daytime Phone Number*
Email address
Waiver Information
Payer*
Waiver*
MN Medicaid PMI #
Payer (Bridgeview, Health Partners, Medica, UCare) ID #
Does the client have a Spenddown or Waiver Obligation?*
- Yes
- No
How much is the Spenddown or Waiver Obligation?*
Service Agreement/Authorization Requested?*
Number of units/meals per week client is authorized to receive:*
Comments

We deliver to this address!