XP: 6 month supervised diet tracking form

A while back someone posted (not sure where) a form they used for the 6 month sup. diet required by insurance.  I've looked high and low and now can't find it.

Does this sound familiar to anyone else?  I have an appointment on Monday with my NP and wanted to make sure the forms were all in order.  If I count the visit in March where we talked about wls, I can submit to insurance in September instead of the end of October!!

Any help would be greatly appreciated!

Is this what you are looking for?


DIET & EXERCISE PROGRAM PROGRESS NOTE
Patients Name__
DOB ____
Date Of Visit____
Date Diet Initiated___
Patient is following a ____kcal/day diet, Other____
Patient is participating in the following exercise regimen ___ (Walking, Swimming, Curves, Yoga, Aerobics, Gym membership, Other, Patient is unable to exercise due to ___)
Vitals: Height___ Weight___ HR___ R____ BP___
Morbid Obesity ___ (check mark here)
Changes in weight since last visit ___ pounds (Lost, Gained, No change)
Continue to follow a ___kcal/day diet, Other___
Continue to exercise___
Return to office in one month to evaluate progress ___
Other________________________________(This is where they fill in education, lifestyle changes, discussion of co morbidities, sleep importance, other things ie. cutting back on soda, coffee, etc....ins. wants to see you're learning what will be necessary) Is this what you are looking for?

That's it!!  Thank you SO MUCH!!!!

No problem!  My PCP loved it when I brought in one already filled out with everything except weight and vitals.  She wrote her notes directly from that--it will definitely help with the documentation that the ins. co. wants to see!

Did you have any trouble getting approval with it? 

Still goin' through the process!!