Cigna 6 Month Weight Loss Documentation
So I am hoping to get my surgery done end of December since my 27 weeks is up on November 1st. I have been looking everywhere on how to document the " medically supervised weight loss" with my PCP and cannot located forms or templates to use. My PCP has never had to document this before. I finally created one and thought I would share with you guys. i even ran it by the cigna people at [email protected] and they said it was fine. I fill out the form once a month with my PCP. She also said it's a good idea to keep a food journal and submit that to your bariatric sugeron. They will submit your PCP forms along with your journal to the insurance company when the time comes to get pre authorization.
Monthly Weight Reduction Progress Name:
DOB: Today’s Date:
Today’s Weight:
Total Weight Loss: Do you smoke? Yes No Do you drink surgary drinks Yes No Do you eat fast food ( McDonalds, Jack In The Box ) at least twice a week? Yes No Do you exercise? Yes No If Yes, Please elaborate: ___________________________________________________________________ Do you drink alcohol? Yes No If Yes, Please elaborate: ___________________________________________________________________ Physician / NP Recommendations: ( SIGN HERE ) PCP / NP NAME, TITLE OFFICE NAME AND LOCATION
Monthly Weight Reduction Progress Name:
DOB: Today’s Date:
Today’s Weight:
Total Weight Loss: Do you smoke? Yes No Do you drink surgary drinks Yes No Do you eat fast food ( McDonalds, Jack In The Box ) at least twice a week? Yes No Do you exercise? Yes No If Yes, Please elaborate: ___________________________________________________________________ Do you drink alcohol? Yes No If Yes, Please elaborate: ___________________________________________________________________ Physician / NP Recommendations: ( SIGN HERE ) PCP / NP NAME, TITLE OFFICE NAME AND LOCATION
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