Primary Care Provider Should Conduct Assessment, Complete Form

Anthem Blue Cross and Blue ShieldState Sponsored Business

Weight Management Program
Qualification Assessment Form

The primary care provider (PCP) should conduct the assessment, complete the form,and fax it to Anthem’s State Sponsored Business Health Services at 18663872840.

To verify eligibility,check Anthem’s ProviderAccess online at or call the AnthemCustomerCareCenter at 18664086132.

Member Information (please print)

Name (first, last): Female Male

CIN/ID Number:DOB: Phone:

Street Address:

City:State:ZIP Code:

Preferred Language:

Provider Assessment

Has the patient been enrolled in a weight management program before, or made previous attempts at weight loss?

No Yes If yes, where, or what type(s)?

How ready is the patient to make a lifestyle change? (1=Not ready 5=ready) 1 2 3 4 5

Comments:

Age:Height: Weight:

Adult Body Mass Index (BMI):

Child/Adolescent BMI Percentile: Below 85th percentile 85th - 94th percentile 95th percentile

Complication(s) and/or Comorbidities: No Yes (please check all that apply)

In Indiana: Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 0308 INW1239 03/31/08

Anthem Blue Cross and Blue ShieldState Sponsored Business

Weight Management Program
Qualification Assessment Form

Arthritis

Asthma

Back pain

Bladder incontinence

Circulatory problems

Depression/mental disorder(s)

Diabetes

Elevated cholesterol/triglycerides

Frequent headaches

Gail bladder disease

Gastric reflux

Hepatic steatosis

High blood pressure

Hyperlipidemia

Hypertension

Pain in weight-bearing joints

Shortness of breath

Sleep apnea

Anthem Blue Cross and Blue ShieldState Sponsored Business

Weight Management Program
Qualification Assessment Form

Other (please specify):

Is the patient interested in receiving the “Get Up and Get Moving!” family workbook (for children ages 6 to 12 and their families)? Yes No

Name of Referring Provider (please print)

SignatureDate

NPI NumberProvider Phone Number

If the patient is under 18 years of age, a parent/legal guardian’s consent is required for enrollment in a weight management program. This does not apply to emancipated minors.

Parent or Guardian’s Full Name (please print)

Parent or Guardian’s SignatureDate

Program Qualification (to be completed by Anthem Health Services)

Based on qualification criteria, patient does not qualify for enrollment in a weight management program.

Based on qualification criteria, patient qualifies for enrollment in a weight management program.