Just Roots Food is Medicine Eligibility Form

Consulta este cuestionario en español

Thank you for your interest in the Just Roots Farm to Family Program!

This tool is intended for:

MassHealth members seeking nutrition-related support
Family members or caregivers supporting someone’s care
Health care providers, care coordinators, and community health workers making or supporting referrals

By submitting this survey, you consent to provide Just Roots with personal information.

If you are eligible for the program, you give Just Roots permission to share your information with your healthcare provider. Please note that prior to your enrollment in the program, the information you provide will be verified by our healthcare partners.

Please provide your contact information:

First Name

Last Name

Date of Birth

Phone

City/Town

Zip Code

Health Plan ID Number

Medicaid ID Number

Please check the box to provide your consent

I understand that I am submitting personal information and I allow Just Roots to share my information solely with my healthcare provider.

Just Roots Food is Medicine Eligibility Form

Eligibility Survey