Get Form #10236

Filling out Form #10236 online is a straightforward process designed to streamline your application for the Comprehensive Weight Management Program. This guide offers clear instructions on how to complete the form efficiently and accurately.

Follow the steps to complete the form easily online.

1. Press the ‘Get Form’ button to receive the form and access it in your preferred digital format.
2. Begin filling in the Member ID number and the patient’s full name, including both last and first names, along with the date of birth in the specified format.
3. Provide the patient’s complete address, including street, city, and zip code, ensuring all information is accurate.
4. Input the home phone number and any additional contact number in the designated fields.
5. Select whether this is an initial request or a retreatment request by checking the appropriate box.
6. Mention the start date of the last program in the specified field.
7. Record the date when weight and height were measured, alongside the current weight and height in the sections provided.
8. Calculate and enter the Body Mass Index (BMI) based on the provided weight and height.
9. Check all applicable criteria related to BMI and co-morbidities that apply to the patient. Be sure to include detailed information regarding any medications for each condition listed.
10. Indicate any contraindications to physical activity by selecting the appropriate option.
11. Fill in the primary care physician's name along with their contact phone number.
12. Provide the necessary signature and fax number for the primary care physician to complete the form.
13. Once you have filled in all the required fields and checked for accuracy, save your changes, download, print, or share the completed form as needed.

Complete your Form #10236 online today and ensure a smooth process for your weight management application.