PHYSICIAN CERTIFICATE OF NEED
Doctor’s Phone: Doctor’s Fax:
From: AGENCY Culver City Senior Nutrition
DATE OF BIRTH
Your patient has requested home delivered meals from our agency. To be eligible for
home delivered meals:
1) person must be age 60 or over: and
2) Person must be homebound due to illness or disability and unable to
prepare his/her own food.
Medical need for service
Estimated length of service
Please note that our meals average 1100 mg Sodium and contain 30-35% fat. Special
diets are not available.
I certify that the above patient qualifies for Home Delivered Meals
Physician’s Signature Date
Please FAX form to agency – Fax number: 310-253-6711
For more information contact: Barbara Silverstein or Roxanna Tabibi at 310-253-6748 or
Statement: I have given permission for Barbara Silverstein (Culver City Senior Nutrition)
to contact my physician.
Client Signature Date