Get Vivify HCG Weight Loss Medical History Form

01 Senile osteoporosis postmenopausal osteoporosis o Other specify ICD-9-CM Prior Treatment History if any o Generic o sodium o sodium o sodium Pertinent Medical History The sample diagnosis codes are informational and not intended to be directive or a guarantee of reimbursement and include potential codes that would include FDA approved indications for . Other codes may be more appropriate given internal system guidelines payor requirements practice patterns and the services rendered. Prescription Information Product Name/Strength 60 mg pre-filled syringe Directions 60 mg SC every 6 months Refill State License Prescriber Signature Fax Completed Form and/or Copy of Insurance Card s to ProliaPlus 1-877-877-6542 Prior to transmittal of any personal health information PHI obtain the legally-required patient authorizations for verification services Trademarks are properties of respective owners. 00 Osteoporosis unspecified o 733. 01 Senile osteoporosis postmenopausal osteoporosis o Other specify ICD-9-CM Prior Treatment History if any o Generic o sodium o sodium o sodium Pertinent Medical History The sample diagnosis codes are informational and not intended to be directive or a guarantee of reimbursement and include potential codes that would include FDA approved indications for . Other codes may be more appropriate given internal system guidelines payor requirements practice patterns and the services rendered. Fax with copies to ProliaPlus 1-877-877-6542 Patient Information Physician Information Patient Name Physician Name Street Address City State Zip Telephone X M o F o Date of Birth Social Security Number Primary Insurance Information o Attach a copy of insurance card front AND back OR Complete insurance information below Name of Insurer Insurer Telephone Subscriber Name Subscriber Social Security Number Subscriber Date of Birth Subscriber Relation to Patient Group Number Policy Number Secondary Insurance Information If there is a preferred fulfillment option please select below o Purchase Buy Bill Pacific Infusion Center 310 297-9269 o I njection Network If preferred Site Name Phone o Other Specialty Site Name Site Street Address Telephone Fax Email address Office Contact Physician Tax ID Physician NPI Payer Specific Provider s for Named Insurance if applicable Patient Medical Information o 733. 00 Osteoporosis unspecified o 733. 01 Senile osteoporosis postmenopausal osteoporosis o Other specify ICD-9-CM Prior Treatment History if any o Generic o sodium o sodium o sodium Pertinent Medical History The sample diagnosis codes are informational and not intended to be directive or a guarantee of reimbursement and include potential codes that would include FDA approved indications for . Family History Health Disease Cause of Death Overweight Father Mother Brothers Sisters Has any blood relative ever had any of the following Glaucoma Yes No Who Asthma Epilepsy High Blood Pressure Yes No Who Kidney Disease Diabetes Tuberculosis Psychiatric Disorder Heart Disease/Stroke Past Medical History check all that apply Polio Jaundice Kidneys Lung Disease Rheumatic Fever Ulcers Anemia Drug Abuse Pneumonia Cholera Arthritis Measles Mumps Scarlet Fever Whooping Cough Bleeding Disorder Gout Heart Valve Disorder Gallbladder Disorder Eating Disorder Malaria Cancer Osteoporosis Tonsillitis Pleurisy Liver Disease Chicken Pox Nervous Breakdown Thyroid Disease Psychiatric Illness Alcohol Abuse Typhoid Fever Blood Transfusion Other Nutrition Evaluation 1. Present Weight Height no shoes Desired Weight 2. Other codes may be more appropriate given internal system guidelines payor requirements practice patterns and the services rendered. Prescription Information Product Name/Strength 60 mg pre-filled syringe Directions 60 mg SC every 6 months Refill State License Prescriber Signature Fax Completed Form and/or Copy of Insurance Card s to ProliaPlus 1-877-877-6542 Prior to transmittal of any personal health information PHI obtain the legally-required patient authorizations for verification services Trademarks are properties of respective owners. MC 47465-B-2 P24281. Paid Vacation Annual Leave Sick Leave Retirement Plan Education Assistance NO Holiday Policy NO Travel Policy includes use of agency vehicles lodging expense advances/documentation mileage reimbursement NO Employee Morale Activities unallowable expense for CACFP account gifts social events meals flowers etc. exceeding 25 NO Other If you do not offer fringe benefits to all of your employees please explain CERTIFICATION STATEMENT I CERTIFY THAT THE INFORMATION ON THIS FORM AND SUBSEQUENT ATTACHMENTS IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT THIS INFORMATION IS BEGIN GIVEN IN CONNECTION WITH THE RECEIPT OF FEDERAL FUND AND THAT DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE STATE AND FEDERALL CRIMINAL STATUES. Any Surgery 15. Family History Health Disease Cause of Death Overweight Father Mother Brothers Sisters Has any blood relative ever had any of the following Glaucoma Yes No Who Asthma Epilepsy High Blood Pressure Yes No Who Kidney Disease Diabetes Tuberculosis Psychiatric Disorder Heart Disease/Stroke Past Medical History check all that apply Polio Jaundice Kidneys Lung Disease Rheumatic Fever Ulcers Anemia Drug Abuse Pneumonia Cholera Arthritis Measles Mumps Scarlet Fever Whooping Cough Bleeding Disorder Gout Heart Valve Disorder Gallbladder Disorder Eating Disorder Malaria Cancer Osteoporosis Tonsillitis Pleurisy Liver Disease Chicken Pox Nervous Breakdown Thyroid Disease Psychiatric Illness Alcohol Abuse Typhoid Fever Blood Transfusion Other Nutrition Evaluation 1. B line 24 CORF NO. TRANSPORTATION 1 Amount from Part I column 6 line 15 4 Unit cost multiplier for CORF A G costs Line 2 divided by line 3 multiply each amount in column 6 lines 2 through 14 Part I by the unit cost multiplier and enter the result on the corresponding line of column 7 ADMINISTRATIVE ALLOCATED A G SEE SUM OF COLS 6 7 05-00 COMPUTATION OF CORF COSTS PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION TOTAL COSTS FROM SUPP. WKST.