Form for a medically supervised diet

Due to many requests--I am going to try to link the form I used to get many of my patients approved.
When I worked for this bariatric surgery group, this is the form we submitted to the insurance for proof of the diet and exercise program. It's simple and to the point. You can use it as a good guideline to make your own. Every insurance I worked with accepted it. You simply use one form for each month, make sure your doc fills out one for each month and signs it!

Good luck!

Bonnie

http://www.parkwestcwlc.com/forms/PWCWLC_PreOpMedDiet.pdf

and here is their website--a GREAT group of people!

http://www.parkwestcwlc.com/index.php