Please fax an enlarged COPY of the front and back of your Type 1 or Type 2 Diabetes, Insulin Controlled ” Type 2 Diabetes, Non-Insulin Controlled ” …
Please fax an enlarged COPY of the front and back of your INSURANCE CARD to
323-442-3351
Step 1: Health Questionnaire
1 Do you have any of the following conditions check all that apply? :
High Blood Pressure Hypertension
Type 1 or Type 2 Diabetes, Insulin Controlled
Type 2 Diabetes, Non-Insulin Controlled
Heart Disease
High Blood Cholesterol
Please list any other conditions:
______________________________________________
________________________________________________________________________
Yes No
2 Has a doctor ever said you have heart trouble or a heart condition?
3 Do you frequently suffer from pains in your chest?
4 Do you often feel faint or have spells of severe dizziness?
5 Has a doctor ever told you that you have a bone or joint problem,
such as arthritis, that has been aggravated or made worse by
exercise?
6 Is there a physical reason, not mentioned here, why it might be
hazardous for you to follow an
activity/nutritional program?
7 Do you have any of the following check all that apply? :
o Asthma
o Shortness of Breath
o Arthritis Bursitis
o Rheumatism
o Hernia
o Recent Surgery
o Gall Stones
o Angina
Yes
No
8 Have you consulted your physician regarding your participation in a
weight loss program?
9 What are your personal goals in regards to this program?
____________________________________________________________________________
____________________________________________________________________________
________________________________________________________________
__
Step 2: Availability - you may skip this section if youve already
selected a group
Please identify which campus, and which days and times, you would be
available for the weekly group meetings Meetings are one hour long, and no
meetings occur on the weekends Most commonly, groups are run between 11:00
AM and 2:00 PM, as well as 5:30 to 9:30 in the evenings Other times
of
day would be considered However, we seek to find approximately 12 people
who are available at the same day, time, and place before initiating a
group
Please circle the campus most convenient for you:
University Park Campus Health Sciences Campus
Near Jefferson Hoover Near Alcazar
Soto
Other please list locations:
____________________________________________________________________________
____
____________________________________________________________________________
____
Please list the times and days most convenient for you:
Monday: ____________________ Tuesday: ______________________
Wednesday: __________________ Thursday: _____________________
Friday: ______________________ Weekends: ____________________
RememberWe can come to you Just get a group of 10 friends, family
members or co-workers together and we can start a group at your location
Step 3: Paying for the Weight Loss Program
We request that all clients make any required co-payments or other
fees, in advance, every eight weeks Therefore, please bring payment for
the eight weeks to your
initial session At your initial session you will
be offered a reference book used during the program This is sold at cost
10, but purchasing the book from this program is completely optional
Please make all checks payable to the USC OT Faculty Practice
Payments made for sessions will apply only to the group in which the
client is enrolled Payments can not roll-over into the following cycle
of groups Credit for sessions will expire once the group has ended
Payments for the USC Lifestyle Redesign Weight Loss Program in the form of
co-pays, co-insurance or private pay are non-refundable Please consider
this financial commitment seriously before signing below No exceptions
will be made
The USC Occupational Therapy Faculty Practice will only allow clients
to make-up two sessions that they have missed This decision was based on
the difficulty finding another group at a day, time, and location that can
be attended, which is covering the material missed, as well as
consideration for the current members of such a group This decision was
also based on a study of our clients that revealed poorer outcomes for
those who
missed more than two sessions versus those who did not
I, , have read and understood the statements
above
Print Name
Signature: Date:
Step 4: Please Review Sign Below
Protecting your privacy is extremely important to us In exchange for
your trust, we promise to observe the following principles: We will ask
only for the information we need in order to provide the highest level of
service to you We will not release personal identifying information about
you without your consent We also ask that all information shared within
the groups, as well as the identities of those within the group sessions
remain confidential
Exercise and health are matters that vary from person to person
Participants in the USC Lifestyle Redesign Weight Loss Program should
speak with their own doctors about their individual needs before starting
any exercise or weight loss program This program is not intended as a
substitute for the medical advice and supervision of your personal
physician Any application of the recommendations set forth within
the
program is at the participants discretion and sole risk
A certified nutrition specialist developed the nutrition program
followed, and some of the information given within the sessions This
information is intended to be used only as a guideline for healthy eating,
and is not meant to be a substitute for a medically prescribed diet If
you are currently on a medically prescribed diet or have any specific
medical conditions that require you to
be on one, please consult your physician In addition, please use your
discretion regarding food allergies and intolerances Although there are a
variety of foods included within the program, it is not recommended that
you consume any foods you are allergic or intolerant to
Please print your name and sign below
I, , have read, understood, and agree to abide by
all of the statements above
Signature: Date:
Please fax an enlarged COPY of the front and back of your INSURANCE CARD to
323-442-3351
OCCUPATIONAL THERAPY REFERRAL FORM
Patient name:
Phone:
Address:
Diagnosis: ICD-9:
Secondary Diagnosis: ICD-9:
History/Precautions:
Physicians Name/ Title:
__________________________Phone:_________________________________
Address:
____________________________________________________________________________
_
Email:
____________________________________________________________________________
___
NPI :__________________________
Please send referral and current history to: USC Occupational Therapy
Faculty Practice
EVALUATION and REPORT
OCCUPATIONAL THERAPY EVALUATION AND TREATMENT
Frequency/Duration: 1x times weekly for 18 weeks
Lifestyle Redesign Weight Loss Program CPT code 97150
Facilitate clients development and enactment of a customized routine of
health promoting and meaningful activities designed to result in improved
life satisfaction and weight-loss
I certify re-certify that I have examined the patient and that
services will be furnished while the patient is under my care, and that the
plan is established and will be reviewed every 30 days, or more often if
the
patients condition requires I estimate that these services will be
needed for about months
_______
PHYSICIANS SIGNATURE DATE
Source:usc.edu
