Weight Management Form Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Start Date* MM slash DD slash YYYY Member's Name* First Last Error Message Provider InformationProvider Name (Ordering MD)* Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Place of service NPI* 10 digitsPlace of service name* Error Message Clinical InformationCPT Code(s) (Click + or - at the right to add up to 5 CPT Codes)*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Member Height (Ex: 5'6")* Member Weight (in lbs)*Member BMI*Weight Related Co Morbid Conditions* History of previous treatment- Please indicate previous attempts and compliance Nutritional Counseling*Nutritional Counseling *YesNoDescribe Compliance*Exercise*Exercise *YesNoDescribe Compliance*Weight Reduction program*Weight Reduction program *YesNoType of program and describe compliance* Referral to Miriam Hospital Weight Loss ProgramDid the member attend the orientation*Did the member attend the orientation *YesNo Note: This is a once per lifetime benefit while a Neighborhood member Has the member ever attended the Miriam Weight Loss Program in the past?*Has the member ever attended the Miriam Weight Loss Program in the past? *YesNoAttach Clinical information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF and Word filesSignature of Physician or Licensed Provider*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA