Bariatric Resource Services Weight Loss Form

This six month weight loss form must be completed in order to confirm you have met the diet requirements
established by your benefit plan. Please bring this form with you to your appointment each month and have it
signed.

 You are required to complete a six month physician supervised diet, prior to surgery. This means that you have worked
with a provider (any licensed Physician, Nurse Practitioner, Nutritionist or Registered Dietician) and had a minimum of one
visit per month for six months.
 During each visit, the provider must document your current weight, what diet regimen you are following and what type and
amount of exercise you are performing. The diet must have been completed within the last two years.
 If you went to Weight Watchers or Jenny Craig, please provide a photocopy of all the stamps and/or written proof of
participation for six months AND at least two physician office visits during this time period.

Patient Name: _________________ ________________ DOB: ___________________________

Patient Subscriber ID:_____________________________________________________________________________

** Please note that documentation is subject to audit by OptumHealth.

Visit Date of Patient Provider Name/Title Provider Signature Education Provided On:
# Visit Weight (printed)
mm/dd/yy (lbs) (Check all that apply)
1  Weight loss regimen
 Type/amount of exercise
 Behavior modification
techniques
2  Weight loss regimen
 Type/amount of exercise
 Behavior modification
techniques
3  Weight loss regimen
 Type/amount of exercise
 Behavior modification
techniques

4  Weight loss regimen

 Type/amount of exercise
 Behavior modification
techniques
5  Weight loss regimen
 Type/amount of exercise
 Behavior modification
techniques
6  Weight loss regimen
 Type/amount of exercise
 Behavior modification
techniques

Patient Signature (Required): X___________________________________________________________________

I declare that the information on this form is true and accurate. I understand that OptumHealth reserves the right to audit this information at any
time.

Return the completed form to:

OptumHealth Bariatric Resource Services

P.O. Box 3520
Lisle, IL 60532

OR FAX to: 855-250-8161

© 2010 OptumHealth, Inc. 1

OptumHealth does not provide health services or practice medicine. The medical centers and programs are independent contractors and are solely responsible
for medical judgments and related treatments. OptumHealth is not liable for any act or omission, including negligence, committed by any independent
contracted health care professional, medical center or program.