Apply — LOOM Rockland

Your details

Tell us about you

Where should we deliver your meal boxes?

First Name*

Last Name*

Date of Birth*

Food Boxes Delivery Address*

Cell Phone Number (for calls and texts)*

Eligibility

Select the health condition that applies to you

Select all that apply. (Optional)

Help us approve your application faster! Declaring health conditions and attaching documents allows us to determine eligibility immediately.

PregnantHad a MiscarriagePostpartum (Last 12 months)Substance Use DisorderHIV / AIDSDiabetesHypertensionSerious Mental Illness (SMI)Chronic ConditionOther

Number of family members (including you)*

Insurance

Insurance information

How would you like to proceed?

Upload a photo of your insurance card to get approved faster — or enter your Medicaid ID (CIN) number below.

💡 Your Medicaid ID (CIN) is the Member ID / CIN# printed on your insurance card — for example, AB12345C. Snap a clear photo of the card, or type the number below. Here's where to look on common cards:

Member ID#:

123456789-00

Member Name: John Sample

FIDELIS CARE

PCP: Samuel Young MD
Member Services:
1-888-343-3547

CIN# ➜CIN#: AB12345C

Fidelis Care — bottom-right

UnitedHealthcare

UCard

Johanna Smith

Member ID 123456789-00⬅ Member ID

AARP Medicare Advantage from UHC
RxBIN 123456 · RxPCN 1234 · RxGRP LNM

UnitedHealthcare — under your name

NEW YORK STATE

ID NUMBERXX00000X⬅ ID Number

DOB 05/03/2007
LAST NAME: LSTN · FIRST: FRST

NY State Benefit — “ID Number”

Upload your insurance card (Recommended for Faster Approval)

Please upload photos of insurance cards for yourself and all family members listed in this application.

⬆

Click to choose a file or drag here

Or enter your Medicaid ID (CIN)

Main applicant's Medicaid CIN