Division of Developmental Disabilities
METABOLIC LOW PROTEIN FOODS ORDERING FORM
VENDOR – Cambrooke Foods
MEMBER NAME (Last, First, M.I.) / AHCCCS ID NUMBERADDRESS (No., Street, City, State, ZIP) / TELEPHONE NUMBER
BAKING
ITEM
NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10301 / CBF All Purpose Baking Mix / 2 lb pouch / $20.99 / $
10302 / CBF MixQuick / 2 lb pouch / $22.49 / $
10303 / CBF Wheat Starch / 2 lb pouch / $16.99 / $
10507 / Butterscotch Chip Cookies / 12 cookies / $19.49 / $
10506 / Peanut Butter Chocolate Chip Cookies / 12 cookies / $19.99 / $
10704 / Pumpkin Raisin Cookies / 12 cookies / $18.49 / $
10312 / Tortilla Wraps / 8 tortillas / $13.99 / $
10317 / Tortilla Chips – Sea Salt / 1 bag, 24 ct / $41.99 / $
10318 / Tortilla Chips – Sweet Chili / 1 bag, 24 ct / $41.99 / $
SUB TOTAL / $
RICE AND PASTA
ITEM
NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10401 / Pasta Solo Elbows / 1/ 8oz box / $9.99 / $
10406 / Pasta Duets Macaroni and Cheese / 1/ 7oz box / $13.49 / $
10407 / Short Grain Rice / 2.3 lb bag / $30.49 / $
10410 / Pasta Duets Creamy Garlic and Broccoli Rice / 1/ 7oz box / $13.49 / $
10428 / Pasta Duets Whiter Cheddar Mac / 1/ 7oz box / $13.49 / $
78709 / Aproten Spaghetti / 1/ 17.6oz bag / $15.99 / $
78839 / Aproten Penne (quills) / 1/ 17.6oz bag / $15.99 / $
78938 / Aproten Fusilli (spirals) / 1/ 17.6oz bag / $15.99 / $
79034 / Aproten Anellini / 1/ 17.6oz bag / $15.99 / $
79119 / Aproten Tagliatelle / 1/ 8.8oz box / $15.99 / $
79317 / Aproten Fettuccine / 1/ 8.8oz box / $15.99 / $
79430 / Aproten Ditalini (little thimbles) / 1/ 17.6oz bag / $15.99 / $
77400 / Aproten Bucatini / 1/ 17.6 oz bag / $15.99 / $
78754 / Aproten Chicchi (little rice) / 1/17.6oz bag / $15.99 / $
79600 / Aproten Linguine / 1/17.6oz bag / $15.99 / $
79700 / Aproten Pipe / 1/17.6oz bag / $15.99 / $
79232 / Aproten Rigatini (large grooved) / 1/17.6oz bag / $15.99 / $
79500 / Aproten Sedani / 1/17.6oz bag / $15.99 / $
SUB TOTAL / $
See page4 for EOE/ADA/LEP/GINA disclosures
DDD-1742E FORFF (3-16) – Page 2
MEMBER NAME (Last, First, M.I.) / AHCCCS ID NUMBERSOUPS AND SEASONINGS
ITEM
NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10309 / Shake ‘N’ Cheese / 1/ 4oz jar / $15.49 / $
10811 / Chicken consommé and Seasoning / 1/ 6oz jar / $15.49 / $
10812 / Alfredo Sauce Mix / 1/ 4.5oz jar / $15.49 / $
10813 / Marinara Minis / 12 marinara sauces / $18.99 / $
10820 / Instant Chicken Noodle Soup / 4 1.5oz packet / $16.99 / $
27074 / Wise Onion Rings / 72. 0.5oz bags / $65.99 / $
SUB TOTAL / $
COLD SHIP ITEMS – Must order at least $50from the sections below in order to ship!!
BREADS
ITEM NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10101 / Artisan Bread / 6 rolls / $15.49 / $
10110 / Homestyle Sliced White Bread / 16 slices / $18.99 / $
10111 / Cinnamon Raisin Swirl Bread / 16 slices / $21.49 / $
10115 / Tuscan Pizza Crusts / 4 crusts / $15.49 / $
10116 / Baby Boule Artisan Bread / 3 boules / $18.49 / $
10123 / Focaccia Sticks Italian Style / 6 sticks / $14.99 / $
10124 / Camburger Buns / 8 buns / $17.99 / $
10608 / Cranberry Scones / 8 scones / $17.49 / $
10610 / Blueberry Scones / 8 scones / $17.49 / $
10611 / Southwestern Biscuits / 6 biscuits / $12.99 / $
10612 / Toaster TopzBanana Chip / 6 topz / $12.99 / $
10614 / Apple Breakfast Bar / 4 bars / $13.49 / $
10616 / Brookelyn Dog Buns / 6 buns / $14.99 / $
10617 / Blueberry Breakfast Bars / 4 bars / $13.49 / $
10618 / Bagels Cinnamon Raisin / 8 bagels / $17.99 / $
10620 / Bagels Onion / 8 bagels / $17.99 / $
10621 / Pita Pockets / 6 pitaz / $18.49 / $
10622 / Bagels Plain / 8 bagels / $17.99 / $
10625 / Bagel Bars French Toast / 8 bars / $17.99 / $
10630 / The Bigger Bagel Plain / 6 bagels / $17.99 / $
10631 / The Bigger Bagel Apple Cinnamon / 6 bagels / $17.99 / $
10632 / The Bigger Bagel Garlic / 6 bagels / $17.99 / $
SUB TOTAL / $
DDD-1742E FORFF (3-16) – Page 3
MEMBER NAME (Last, First, M.I.) / AHCCCS ID NUMBERCHEESE
ITEM
NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10314 / Cheddar Shreds / 1/ 2lb bag / $16.99 / $
10315 / Mozzarella Shreds / 1/ 2lb bag / $16.99 / $
10308 / Cheddar Wizard / 1 container / $8.99 / $
20311 / American Cheese Singles / 2 pack / 1/ 32 slices / $17.99 / $
20312 / Swiss Cheese Singles / 2 pack / 1/ 32 slices / $17.99 / $
20313 / Jalapeno Cheese Singles / 2 pack / 1/ 32 slices / $17.99 / $
SUB TOTAL / $
FRESH FILLED PASTA
ITEM
NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10411 / Portabella Spinach Ravioli / 1/ 1 lb bag / $29.99 / $
10412 / Pierogi / 1/ 1 lb bag / $26.99 / $
10413 / Cheese Ravioli / 1/ 1 lb bag / $26.99 / $
10429 / Toasted Pierogies / 1/ 2lb box / $49.49 / $
SUB TOTAL / $
MEAT ALTERNATIVES
ITEM NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10901 / Camburgers / 4 burgers / $15.99 / $
10902 / Tweekz / 9 nuggets / $19.99 / $
10911 / Veggie Meatballs / 1/ 1lb 2 oz bag / $28.49 / $
10915 / Corny Dogs / 8 servings / $22.99 / $
10917 / Cheese Filled Meatballs / 1/ 1lb 4 oz bag / $30.49 / $
10918 / Brookelyn Dogs / 16 dogs / $36.49 / $
SUB TOTAL / $
READY MEALS
ITEM
NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10313 / CBF Eggz / ¼ c mix / $23.49 / $
10903 / Cheese Pizza / 3 pizzas / $30.49 / $
10904 / Pizza Blanca / 3 pizzas / $30.49 / $
10908 / Pizza Primavera / 3 pizzas / $30.49 / $
10919 / Medley Meals Vegetable Masala / 1 meal / $13.99 / $
10920 / Medley Meal Barbecue Bake / 1 meal / $13.99 / $
10921 / Medley Meal Thai / 1 meal / $13.99 / $
10930 / GO Pockets – Cheesy Broccoli / 2 pockets / $12.59 / $
10931 / GO Pockets Burrito / 2 pockets / $12.59 / $
10932 / GO Pockets Samosa / 2 pockets / $12.59 / $
SUB TOTAL / $
DDD-1742E FORFF (3-16) – Page 4
MEMBER NAME (Last, First, M.I.) / AHCCCS ID NUMBERSNACKS AND DESSERTS
ITEM NUMBER / PRODUCT / UNITS
PER CASE / CASE
PRICE / QTY
ORDERED / COST
10505 / Gourmet Chocolate Chip Cookie Dough / 1/ 3lb tub / $25.99 / $
10607 / Sugar Cookie Dough / 1/ 3lb tub / $28.99 / $
10750 / Fudgy Brownies / 6 brownies / $11.99 / $
10701 / Chocolate Cha Cha’s / 25 bars / $31.99 / $
10702 / Raspberry Gems / 24 cookies / $20.99 / $
10703 / Cinnamon and Raisin Gems / 24 cookies / $20.99 / $
10909 / Mini Pockets Pizza / 6 pockets / $14.99 / $
10913 / Mini Pockets PB&J / 6 pockets / $14.99 / $
10306 / Pea-Not Butter / 1 container / $10.99 / $
SUB TOTAL / $
GRAND TOTAL / $
Order reviewed by (Print Name) / Date Order reviewed
Signature (Not valid unless signed by the Metabolic Clinic Physician or Registered Dietician)
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contactthe Division of Developmental Disabilities ADA Coordinator at 602-542-0419; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones relacionadas a los servicios del DES está disponible a solicitud del cliente.