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    Ryans World Squad Goals

    Uploaded by

    Melinda
    This document is a six month weight loss form that must be completed by patients to meet benefit plan requirements for weight loss surgery. It requires one physician visit per month documenting weight, diet, and exercise over six months.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Ryans World Squad Goals

    Uploaded by

    Melinda
    92 views1 page
    This document is a six month weight loss form that must be completed by patients to meet benefit plan requirements for weight loss surgery. It requires one physician visit per month documenting weight, diet, and exercise over six months.

    Original Description:

    weight loss

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    This document is a six month weight loss form that must be completed by patients to meet benefit plan requirements for weight loss surgery. It requires one physician visit per month documenting weight, diet, and exercise over six months.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    92 views1 page

    Ryans World Squad Goals

    Uploaded by

    Melinda
    This document is a six month weight loss form that must be completed by patients to meet benefit plan requirements for weight loss surgery. It requires one physician visit per month documenting weight, diet, and exercise over six months.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Bariatric Resource Services Weight Loss Form

    This six month weight loss form must be completed in order to confirm you have met the diet requirements
    established by your benefit plan. Please bring this form with you to your appointment each month and have it
    signed.

     You are required to complete a six month physician supervised diet, prior to surgery. This means that you have worked
    with a provider (any licensed Physician, Nurse Practitioner, Nutritionist or Registered Dietician) and had a minimum of one
    visit per month for six months.
     During each visit, the provider must document your current weight, what diet regimen you are following and what type and
    amount of exercise you are performing. The diet must have been completed within the last two years.
     If you went to Weight Watchers or Jenny Craig, please provide a photocopy of all the stamps and/or written proof of
    participation for six months AND at least two physician office visits during this time period.

    Patient Name: _________________ ________________ DOB: ___________________________

    Patient Subscriber ID:_____________________________________________________________________________

    ** Please note that documentation is subject to audit by OptumHealth.

    Visit Date of Patient Provider Name/Title Provider Signature Education Provided On:
    # Visit Weight (printed)
    mm/dd/yy (lbs) (Check all that apply)
    1  Weight loss regimen
     Type/amount of exercise
     Behavior modification
    techniques
    2  Weight loss regimen
     Type/amount of exercise
     Behavior modification
    techniques
    3  Weight loss regimen
     Type/amount of exercise
     Behavior modification
    techniques

    4  Weight loss regimen


     Type/amount of exercise
     Behavior modification
    techniques
    5  Weight loss regimen
     Type/amount of exercise
     Behavior modification
    techniques
    6  Weight loss regimen
     Type/amount of exercise
     Behavior modification
    techniques

    Patient Signature (Required): X___________________________________________________________________

    I declare that the information on this form is true and accurate. I understand that OptumHealth reserves the right to audit this information at any
    time.

    Return the completed form to:

    OptumHealth Bariatric Resource Services


    P.O. Box 3520
    Lisle, IL 60532

    OR FAX to: 855-250-8161

    © 2010 OptumHealth, Inc. 1


    OptumHealth does not provide health services or practice medicine. The medical centers and programs are independent contractors and are solely responsible
    for medical judgments and related treatments. OptumHealth is not liable for any act or omission, including negligence, committed by any independent
    contracted health care professional, medical center or program.

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