Get Tx Scott & White Health Plan Weight Management Referral Form 2013-2025

Filling out the TX Scott & White Health Plan Weight Management Referral Form online can streamline the referral process for both providers and patients. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the referring provider's printed name in the designated field. This identifies who is referring the patient.
3. Fill in the provider's phone number, fax number, email address, and either NPI or SWID number. This information is essential for communication.
4. Indicate that you are referring the patient by confirming their commitment to the weight management program, which includes routine visits and adherence to the meal plan.
5. Include your signature and the date to certify the referral.
6. Next, provide the patient’s details including their name, date of birth (DOB), and address.
7. Complete the patient’s contact information by entering their home phone number and daytime phone number.
8. Input the patient’s insurance ID number, followed by the cardholder's name and date of birth.
9. Record the patient's current height, current weight, goal weight, and ideal weight in their respective fields.
10. If applicable, provide a history of arrhythmias and record vital signs including blood pressure and pulse.
11. Document cholesterol levels, triglycerides, HDL, LDL, serum creatinine, potassium, uric acid, and A1c levels if the patient has diabetes.
12. Once all fields are filled out, review the form for accuracy, then save changes, download, print, or share the form as needed.

Complete the TX Scott & White Health Plan Weight Management Referral Form online today for efficient processing!