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

What brings you to LOOM?

Select all that apply.

Pregnancy – Expecting mothersPostpartum – New mothers (typically up to 1 year after birth)Food Insecurity – Difficulty affording or accessing nutritious foodHousing Insecurity – At risk of eviction, homelessness, or struggle to pay rentDiabetes – Managing blood sugar through dietHypertension – High blood pressure requiring healthy nutritionHeart Conditions – Chronic heart disease supportObesity – Need for nutritional support for weight managementMental Health Challenges – Depression, anxiety, or other mental health strugglesDevelopmental Disabilities – Autism, Down syndrome, or other delaysPhysical Disabilities – Mobility issues affecting food accessSubstance Use Disorder – Support for those in recoveryMedicaid Membership – Holders of Healthfirst, Fidelis, United, etc.Public Assistance – Individuals receiving SNAP, WIC, SSI, or TANF

Number of family members (including you)*

Insurance

Insurance information

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)⚡ Approved faster

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*