Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to download the form and open it in the editor.
2. Begin by entering the member information in the designated fields, including the first and last name, date of birth, phone number, and address.
3. Indicate the gender of the member by selecting either 'Male' or 'Female'.
4. Fill in the member's CIN/ID Number and preferred language.
5. In the provider assessment section, provide details about the member's previous weight management attempts by selecting 'Yes' or 'No.' If 'Yes,' specify the type of program.
6. Rate the member's readiness for lifestyle change on a scale from 1 (not ready) to 5 (ready), and include any additional comments.
7. Complete the member's age, height, weight, and Body Mass Index (BMI) in the appropriate fields.
8. Identify the child's BMI percentile if applicable, and check any relevant complications or comorbidities.
9. Note the interest in receiving the 'Get Up and Get Moving!' workbook by selecting 'Yes' or 'No'.
10. In the referring provider section, print the provider's full name, signature, NPI number, date, and phone number.
11. If the member is under 18, ensure that a parent or guardian completes their section, providing their full name, signature, and date.
12. Finally, review all entries for accuracy, then save your changes, and proceed to download, print, or share the completed form.

Complete your documents online today to efficiently manage your weight management program enrollment.