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Step 2 of 5

Please provide your contact details so we can send you your meals.
Name*
First Last
Email*
No Email Address
- I don't have an email address
Phone*
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Step 3 of 5
What language would like to receive communications in?*
- English
- Spanish
How would you like to receive program communications?*
- Text
- Email
- Both
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memberid
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- Dev
- Prod
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peopleid
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entryid
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benefit_type
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What can this meal service support you with?*
Select up to 2 choices below:
- Diabetes
- Congestive heart failure
- Chronic kidney disease
- Hypertension
- High cholesterol
- None of the above
Do you currently track your blood sugar levels at home?*
- Yes
- No
Would you like to enroll in additional support for managing and monitoring your blood sugar?
- - Choose the days of the week and time(s) you want to receive reminders. 
- - Each reminder sends you to a secure webpage where you can enter your reading.  
- - Log in anytime to see your readings.
- Yes
- No
Choose when would you like to receive reminders
Morning Afternoon Both None
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Step 4 of 5

Want a caregiver, partner, family member, loved one or support person to receive messages as well?
Add Members*
- Yes
- No
Enter their details here.
Name
First Last
Phone
Email
They Speak:
- English
- Spanish

Step 5 of 5
Please accept the Terms and conditions:*
- I have read and agreed to the terms and conditions of this program.
- I agree to receive periodic text messages and/or emails related to this program, my condition and the services offered to me through my health plan. I understand that text and email are not considered secure technologies and that the messages I receive may indicate the nature of my condition. However, beyond the general nature of my condition, this program does not send protected health information (PHI) via text. I understand that the program uses text messages from my text plan and there are no additional charges.  
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