FIRST TIME QUESTIONNAIRE

First Time Questionnaire Form

Provider Information

Provider First Name *

Provider Last Name *

Provider NPI Number *

Provider License Number *

Provider DEA Number *

Provider Email *

Provider Phone *

Provider Fax *

Member First Name *

Member Last Name *

Member Date of Birth *

Member Social Security # (9 digits, No dash or Space) — required unless Employer Employee ID + Dependent Number are provided

Member Email *

Member Phone *

Enter at least 10 digits

Member Address Line 1 *

Member Address Line 2

Member City *

Member State *

Member ZIP Code *

Drug Name *

Quantity *

Day Supply *

Weight in Pounds *

Range: 50-800 lbs

Height in Inches *

Range: 36-96 inches (3-8 ft)

BMI (Body Mass Index) *

Do you have Prediabetes, Hypertension, Kidney Disease, Heart Failure or any Cardiovascular diseases? *

Secure submission. Your information is sent securely, and any files you upload are stored privately and available only to authorized reviewers. Please enter only the information needed to review this request.

Please read the following information prior to completing this form.

Please fill out this form to request eligibility for your patient. Your patient will not be able to participate in the program or seek reimbursement for GLP-1 drugs without having first completed this form and having been approved.
Submission will be reviewed and you will be notified of a decision within 3 days.
Once you have received approval email, your being will be able to use this benefit for the purchase of GLP-1 drugs.
I certify that the information provided is accurate and reflects my clinical evaluation of this patient.
I am the treating provider for this patient.
I am prescribing or supervising the patient’s use of a GLP 1 medication for weight management purposes.
In my clinical judgment, GLP 1 therapy is appropriate for this patient.