Weight Management Program Qualification Assessment ... - UniCare by qingyunliuliu


									                                                                               UniCare Health Plan of West Virginia, Inc.
                                                                                               Medicaid Managed Care
                                                                                             Weight Management Program
                                                                                           Qualifications Assessment Form
     The primary care provider (PCP) should conduct the assessment, complete the form, and fax it to the
     UniCare Community Resource Center (CRC) at 1-888-338-1320. If you have questions, call the CRC at
     To verify eligibility, check UniCare’s provider AccessPoint online at www.unicare.com/home-
     providers.html or call the UniCare Customer Care Center at 1-800-782-0095.
     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


     Age:                                       Height:                                    Weight:

     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)
       Arthritis                                     Diabetes                                 High blood pressure
       Asthma                                        Elevated cholesterol/triglycerides       Hyperlipidemia
       Back pain                                     Frequent headaches                       Hypertension
       Bladder incontinence                          Gail bladder disease                     Pain in weight-bearing joints
       Circulatory problems                          Gastric reflux                           Shortness of breath
       Depression / mental disorder(s)               Hepatic steatosis                        Sleep apnea
        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)

     Signature                                                                                                  Date

     NPI Number                                                     Provider 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 Signature                                                                Date
     Program Qualification (to be completed by UniCare 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.

UniCare Health Plan of West Virginia, Inc., ® Registered mark of WellPoint, Inc.                            0308 WVW1239 Rev: 11/21/2012

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