RENEWAL QUESTIONNAIRE

Renewal 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 *

Have you adhered to a reduced-calorie diet AND increased physical activity? *

Have you experienced 5% or more weight loss from baseline? *

Override First Time Questionnaire Requirement? (Optional)

Select "Yes" if you have not previously completed a First Time Questionnaire but are requesting renewal approval.

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 6 months after ther First Questionnaire 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, patient will be able to continue using this benefit for the purchase of GLP-1 drugs.
I certify that the patient remains under my care and is medically appropriate to continue GLP 1 therapy.
I am continuing to prescribe or supervise GLP 1 therapy.
I am the treating provider for this patient.
The patient is medically appropriate to continue GLP 1 therapy at this time.
No concerns at this time regarding continuation of therapy.