Commit to Fit! Weight Assessment: Child (Under Age 18)
|
|
- Edwin Stevenson
- 5 years ago
- Views:
Transcription
1
2
3 Commit to Fit! Weight Assessment: Child (Under Age 18) DEMOGRAPHICS (To be filled out by the patient or patient guardian) First & Last Name: DOB: Gender (Circle One): M F Address: Preferred Phone: Home Cell Work (Circle One) Race/Ethnicity (Circle One): White African American American Indian Asian Indian Japanese Chinese Other (Please List): Language (Circle One): English Spanish Other (Please List): BMI MEASUREMENT (To be filled out by the physician) Date: Height: Weight: BMI: = weight (lb) / [height (in)] 2 x 703 BMI Classification (Check One): Underweight (BMI <5th percentile) Healthy Weight (5th percentile to 85th percentile) Overweight (85th percentile to <95th percentile) Obese (BMI 95th percentile) HEALTHY BEHAVIORS ASSESSMENT (To be filled out by the patient or patient guardian) How many servings of fruits and vegetables do you eat a day? How many times a week do you eat dinner at the table with your family? How many times a week do you eat breakfast? How many tmes a week do you eat takeout or fast food? How many hours a day do you watch TV/movies or sit and play video/computer games? Do you have a TV in your room where you sleep? Do you have a computer in your room where you sleep? How many hours of sleep do you get per night? How much time a day do you spend in active play (faster breathing/sweating)? How many 12-ounce servings of the following do you drink a day (12 oz. = 1 can of soda or pop): 100% Juice: Fruit or Sports Drinks: Soda or Punch: Water: Whole or 2% milk: 1% or Skim Milk: Please rate your stress level below (Circle a Number): Little or no stress PHYSICIAN ADDITIONAL NOTES A great deal of stress. Physician Signature: Patient/Guardian Signature: Date: Date: HEALTH-8B4 weightassessement.child ar
4 Commit to Fit! Weight Assessment: Adult (18 and Over) DEMOGRAPHICS (To be filled out by the patient) First & Last Name: DOB: Gender (Circle One): M F Address: Preferred Phone: Home Cell Work (Circle One) Race/Ethnicity (Circle One): White African American American Indian Asian Indian Japanese Chinese Other (Please List): Language (Circle One): English Spanish Other (Please List): BMI MEASUREMENT (To be filled out by the physician) Date: Height: Weight: BMI: = weight (lb) / [height (in)] 2 x 703 BMI Classification (Check One): Underweight (BMI <18.5) Healthy Weight (BMI ) Overweight (BMI ) Obese (BMI>30.0) HEALTHY BEHAVIORS ASSESSMENT (To be filled out by the patient) How many servings of fruits and vegetables do you eat a day? How many times a week do you eat breakfast? How many times a week do you eat takeout or fast food? How many hours a day do you watch TV/movies or sit and play video/computer games? Do you have a TV in your room where you sleep? Do you have a computer in your room where you sleep? How many hours of sleep do you get per night? How much time a day do you spend in active play (faster breathing/sweating)? How many 12-ounce servings of the following do you drink a day (12 oz. = 1 can of soda or pop): 100% Juice: Fruit or Sports Drinks: Soda or Punch: Water: Whole or 2% Milk: 1% or Skim Milk: Please rate your stress level below (Circle a Number): Little or no stress PHYSICIAN ADDITIONAL NOTES A great deal of stress. Physician Signature: Patient Signature: Date: Date: HEALTH-8B4 weightassessement.adult ar
5 Child Healthy Weight Plan (Child s Name) (Caregiver s Name) SETTING A GOAL (to be filled out by caregiver and child together) Here are some things other people have decided to do for their health. I would like to set goal(s) to: Eat at least 5 servings of fruit/vegetables a day Avoid pop and other sugary drinks Get at least 60 minutes of physical activity every day Limit screen time (computers, video games and TV) Eat healthy dinners with my family regularly Eat or drink 3 servings of dairy daily Get enough sleep Other: ACHIEVING MY GOAL (to be filled out by caregiver and child together) 1. How important is it to me to make this change? (Circle One) Not at all important Extremely important 2. What might make it difficult for me to achieve my goal (what are the barriers)?. 3. How confident am I that I can carry out this plan? (Circle One): Not at all confident Extremely confident 4. I agree to this plan of action and will review my plan and progress on with by (Date). REFERRALS (to be filled out by caregiver only) I need more information about how to improve my child s health! I want him or her to: Register as a user on and log onto the website daily with me. See their primary care doctor, (Name) by. See a dietician or nutritionist to talk about healthy eating. Be referred to community agencies where he/she can exercise. See a therapist or social work to discuss his/her emotional and social health. You can use various Commit to Fit! tools based on the patients identified goals. See the the Supplemental Materials section for a complete list of tools. All patients should register as users on the website, as it addresses all health goals. I give my permission to forward this information about my child s health assessment and plan to the health professional(s) I want him/her to see. Signature of Parent/Guardian: Date: HEALTH-8B4 hwplan.child.version ar
6 Adult Healthy Weight Plan (Name) SETTING A GOAL Here are some things other people have decided to do for their health. I would like to set goal(s) to: Eat at least 5 servings of fruit/vegetables a day Avoid sugar-sweetened beverages Get at least 60 minutes of physical activity every day Limit screen time (computers, video games and TV) Monitor my weight status regularly Manage my stress Get enough sleep Other: ACHIEVING MY GOAL 1. How important is it to me to make this change? (Circle One) Not at all important Extremely important 2. What might make it difficult for me to achieve my goal (what are the barriers)?. You can use various Commit to Fit! tools based on the patients identified goals. See the the Supplemental Materials section for a complete list of tools. 3. Steps I will take to make this change (include the what, when, how and with whom): a.. b.. c.. d.. 4. How confident am I that I can carry out this plan? (Circle One): Not at all confident Extremely confident 5. Information or support I might need in accomplishing my goal:. 6. I will know my plan is working when:. 7. I will celebrate my success by:. 8. I agree to this plan of action and will review my plan and progress on with REFERRALS by (Date). I need more information about how to improve my health! I want to: Register as a user on and log onto the website daily. See my primary care doctor, (Name) by. See a dietician or nutritionist to talk about healthy eating. Be referred to community agencies where I can exercise. See a therapist or social work to discuss my emotional and social health. All patients should register as users on the website, as it addresses all health goals. I give my permission to forward this information about my health assessment and my plan to the health professional(s) I want to see. Signature of Individual: Date: HEALTH-8B4 hwplan.adult.revised ar
7 Reimbursement for Obesity Counseling Using Commit to Fit! Physician s Toolkit The following information represents physician reimbursement options when utilizing the Commit to Fit! Weight Assessment and Healthy Weight Plan for obesity counseling. Medicare Coverage CMS Guidelines for Obesity Counseling Coverage & Services Obesity Counseling o Face-to-Face o Provided by a primary care physician o Provided in a primary care setting o Minimum 15 minute sessions o Patient BMI 30 o Maximum of 22 visits allocated in a 12 month period 1 visit per week in first month 1 visit every other week in months visit every month for months 7-12 if patient has met the 6.6 lb. weight loss requirement in first six months ICD-9 Diagnostic Code Other Medicare Coverage for Obesity Counseling V85.30 V85.40 series NOTE: The V85 series code for obesity must be included in a patient s diagnosis in order to use the G0477 obesity counseling code CPT/HCPCS Code G0447 NOTE: G0477 may be billed in addition to a regular E & M coded visit (in this case patient would not have a copay for these services) Reimbursement Amount $24.50 Both Blue Cross Blue Shield of Michigan and HealthPlus of Michigan Medicare Plans follow CMS guidelines and offer the same reimbursement. Commercial Insurance Coverage for Obesity Counseling Insurer Specific Plan ICD-9 Diagnostic Code Blue Cross Blue Shield of Michigan HealthPlus of Michigan McLaren Health Plan Commercial Plan: Coverage varies depending on group - if covered, copays may apply to services provided by outof-network providers Follows CMS Guidelines if covered, copays may apply to services provided by outof-network providers Currently does not offer reimbursement for obesity counseling CPT/HCPCS Code Reimbursement Amount Physician s office should consult BCBSM for billing and reimbursement amounts for commercial clients. V85.30 V85.40 series G0447 $21.25 N/A N/A N/A
8
9
10
11
Healthy Active Arkansas Rethink Your Drink: Choose Water Funding Application
Healthy Active Arkansas Rethink Your Drink: Choose Water Funding Application The goal of Healthy Active Arkansas is to increase the percentage of adults, adolescents and children who are at a healthy weight.
More informationEVALUATING AN EVIDENCE-BASED PROGRAM THAT ADDRESSES CHILDHOOD OBESITY IN A MIDDLE SCHOOL. Christina Smith. A Senior Honors Project Presented to the
EVALUATING AN EVIDENCE-BASED PROGRAM THAT ADDRESSES CHILDHOOD OBESITY IN A MIDDLE SCHOOL by Christina Smith A Senior Honors Project Presented to the Honors College East Carolina University In Partial Fulfillment
More informationWELLNESS POLICY. The Village for Families & Children Revised 11/10/2016 Page 1 of 7
WELLNESS POLICY Comments/feedback welcomed as part of the annual review/revision process. Please see section VI below that addresses the most recent evaluation and progress made in attaining the goals
More informationMN Partnership for Pediatric Obesity Care and Coverage (MPPOCC)
MN Partnership for Pediatric Obesity Care and Coverage (MPPOCC) Best Practice Guidelines in Clinic/Community Collaborative Pediatric Obesity Services Presented to: MPPOCC Members and SHIP Grantees January
More informationYour Wellness Visit Guide
Your Wellness Visit Guide Prepare for your Annual Wellness Visit or Welcome to Medicare Visit. Let s make the most of your appointment. Annual Wellness Visit Provider Toolkit Caring for Seniors HIGHMARK.COM
More informationNutritional Health Questionnaire
Name: Today s date: Address: City: State: Zip: Email address: Skype contact (if applicable): Home Phone: Work phone: Cell Phone: What numbers are best for detailed messages? What is your preferred method
More informationWellness Goal Nutrition Messages
Wellness Policy Arlington House provides emergency shelter for adolescents 11 through 17 years of age, for up to 90 days, while placements are arranged. Arlington House will accept referrals for clients
More informationPrevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement
Prevention, assessment and treatment of childhood obesity: Closing the gap in provider reimbursement 1. Overview of the Healthier Generation Benefit 2. Review of expert committee recommendations and U.S.
More informationBehavioral Pediatric Screening
SM www.bluechoicescmedicaid.com Volume 3, Issue 5 June 2015 Behavioral Pediatric Screening Clinical recommendations, as well as behavioral pediatric screening best practices, indicate that you should administer
More informationTools for Better Health. Referral Toolkit. Health Care Providers
Tools for Better Health Referral Toolkit Health Care Providers A guide to working with providers to establish a referral system for evidence-based self-management programs. Table of Contents How to Use
More informationFCPS Wellness Policy and Regulations
FCPS Wellness Policy and Regulations School Health Advisory Committee 2016 Recommendations to the Fairfax County School Board Purpose Place the health and wellness of FCPS students and staff members at
More informationNPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
More informationTopic 3. for the healthy lifestyle: noncommunicable diseases (NCDs) prevention and control module. Topic 3 - Community toolkit.
213mm Topic 3 Community toolkit for the healthy lifestyle: noncommunicable diseases (NCDs) prevention and control module In partnership with: International Federation of Pharmaceutical Manufacturers &
More informationTrinity Health Healthy Blue Solutions SM Plan Year. January 1 December 31. Benefit Plan Coverage Comparison Guide
Trinity Health Healthy Blue Solutions SM 2013 Plan Year January 1 December 31 Benefit Plan Coverage Comparison Guide Contents The Trinity Health Healthy Blue Solutions Program...2 How to take your BlueHealthConnection
More informationHappen Quarter 1, 2013
Amerigroup Community Care MakeHealth Happen Quarter 1, 2013 Screenings that Save Lives Things to know: Learning you are healthy can help bring peace of mind Screenings may help find growths before they
More informationALL MENTAL HEALTH AND SUBSTANCE USE DISORDER PROGRAMS MUST INCLUDE PSYCHOSOCIAL AND PSYCHIATRIC EVALUATIONS
COUNTY of NASSAU DEPARTMENT OF HUMAN SERVICES Office of Mental Health, Chemical Dependency and Developmental Disabilities Services 60 Charles Lindbergh Boulevard, Suite 200, Uniondale, New York 11553-3687
More information2012 Healthy Campus Grant Application
2011 HEB, 11-2744CS 2012 Healthy Campus Grant Application in cooperation with the Texas Education Agency Purpose The H-E-B Excellence in Education Healthy Campus grant is designed to assist school campuses
More informationFOOD TEMPERATURES. Foods will be maintained at proper temperature to insure food safety.
FOOD TEMPERATURES Foods will be maintained at proper temperature to insure food safety. 1. The point of service temperature to residents will be within the range of 120-140 degrees based on the resident's
More informationUNIVERSAL INTAKE FORM
CLIENT DEMOGRAPHICS Agency Name: Fiscal Year: Funding Identifier: UNIVERSAL INTAKE FORM Title III B C1 C2 Title III D Title III E Title III E(G) 1 Linkages SNAP-Ed Applicant Last Name First Name Middle
More informationUNIVERSAL INTAKE FORM
Agency Name: Funding Identifier: Los Angeles County Area Agency on Aging UNIVERSAL INTAKE FORM Title IIIB Title C1 Title C2 Title IIIE Title IIIE(G) Linkages IDENTIFICATION DEMOGRAPHICS 1a Date: Applicant
More informationVICTORIA REGIONAL JUVENILE JUSTICE CENTER
VICTORIA REGIONAL JUVENILE JUSTICE CENTER Policy No: 11.6 Pages: 6 Chapter: Food Service Related Standards USDA Dietary Guidelines for Subject: Wellness Policy on Physical Activity & Nutrition Americans
More informationWatch Your Weight, Eat Healthy and Exercise More
SOUTH CAROLINA 2016 ISSUE I Watch Your Weight, Eat Healthy and Exercise More Did you know that South Carolina s adult obesity rate is 31.7%? That makes it the 10th highest adult obesity rate in the nation.
More informationNRPA/Walmart Foundation 2017 Healthy Out-of-School Time Grant Application
NRPA/Walmart Foundation 2017 Healthy Out-of-School Time Grant Application Introduction The National Recreation and Park Association (NRPA) is pleased to announce the availability of grant funds from the
More informationMEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS
PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS Effective Date: September 8, 2014 Review Dates: 10/07, 10/08, 10/09, 6/10, 6/11, 6/12, 6/13, 8/14, 8/15, 8/16, 8/17 Date Of Origin:
More informationCare Management Policies
POLICY: Category: Care Management Policies Care Management 2.1 Patient Tracking and Registry Functions Effective Date: Est. 12/1/2010 Revised Date: Purpose: To ensure management and monitoring of patient
More informationFrom: AR Center (Arkansas Center for the Study of Integrative Medicine)! PLEASE READ FIRST!!
From: AR Center (Arkansas Center for the Study of Integrative Medicine) PLEASE READ FIRST Please be sure that you have a QUALIFYING MEDICAL CONDITION for Medical Marijuana in Arkansas. If you do not have
More informationMONROE COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017
MONROE COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Monroe County. Where possible, benchmarks
More informationPreventive Health Guidelines
Preventive Health Guidelines Section N-1 Overview The objective of Molina Healthcare of New Mexico, Inc. (Molina Healthcare) is the delivery of a core package of clinical preventive health services that
More informationNEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT MAILING DOCTOR S NAME: PLEASE EXPLAIN: DOCTOR S NAME: RESULTS:
ABOUT THE CHILD CHIROPRACTIC EXPERIENCE NAME: WHO REFERRED YOU TO OUR OFFICE? ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: HOW DID YOU HEAR ABOUT OUR OFFICE (ALL THAT APPLY): NEWSPAPER SIGN YELLOW PAGES
More informationResponsible Party Information (Information used for patient balance statements) Responsible Party Another Patient Guarantor Self
Patient Information (Please Print) Dr. Miss Mr. Mrs. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Home Phone Cell No. Work Phone Ext. Primary Care Provider (PCP)
More informationPediatric New Patient Intake Form
Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Email: Gender: Primary Pediatrician: Pediatrician Address:
More informationImplementation Guide. gfhc.org. An opportunity to improve patient outcomes, medical practice efficiency, and provider productivity
Medical GROUP VISITS Implementation Guide An opportunity to improve patient outcomes, medical practice efficiency, and provider productivity Greater Flint Health Coalition June 2013 gfhc.org The goal of
More informationSTEUBEN COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017
STEUBEN COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Steuben County. Where possible, benchmarks
More informationNEW PATIENT INFORMATION: ADULT
NEW PATIENT INFORMATION: ADULT Patient Last Name: Patient First Name: Patient Middle Name: DOB: Sex: M F SSN: Address: City: Zip: Home Phone: Cell Phone: Email: EMERGENCY CONTACT INFORMATION Last Name:
More informationSay Something Join ASAP! ASAP!
Say Something Join ASAP! ASAP! What is ASAP? ASAP stands for the Asian American Student Advocacy Project, a leadership program for Asian Pacific American (APA) high school students who want to learn how
More informationLIVINGSTON COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017
LIVINGSTON COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Livingston County. Where possible,
More informationPINE REST CHRISTIAN MENTAL HEALTH SERVICES COMMUNITY AND RESIDENTIAL SERVICES CENTER FOR PSYCHIATRIC RESIDENTIAL SERVICES. Wellness Policy APPROVAL:
PINE REST CHRISTIAN MENTAL HEALTH SERVICES COMMUNITY AND RESIDENTIAL SERVICES CENTER FOR PSYCHIATRIC RESIDENTIAL SERVICES Wellness Policy Departmental Policy: Date of Original Document: March 2016 Date
More informationNutrition Education, Physical Education, Foods and Beverages and other Wellness Activities
Students BP 5030(a) STUDENT WELLNESS The Board of Trustees recognizes the link between student health and academic success and desires to provide a comprehensive program promoting healthy eating and physical
More informationPATIENT REGISTRATION FORM (ecw)
PATIENT INFORMATION PATIENT REGISTRATION FORM (ecw) (Please print) Patient s Name: (Last) (First) (MI) Address: City, State, Zip: Home: Cell: Work: E-Mail Address: DOB: Sex: Female Male Transgender Race:
More informationCHEMUNG COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017
CHEMUNG COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Chemung County. Where possible, benchmarks
More information21 st Century Charter School at Gary Policy ID School Wellness Policy Policy # July 5, 2006 WELLNESS POLICY
21 st Century Charter School at Gary Policy ID School Wellness Policy Policy # July 5, 2006 WELLNESS POLICY As required by law, the Board of Education establishes the following wellness policy for the
More informationSoutheast Michigan Beacon Community
Southeast Michigan Beacon Community Background and Information on Text HEALTH November 8, 2011 1 Beacon Communities Funded by U.S. Department of Health and Human Services Administered by the Office of
More informationThey are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see:
bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest
More informationPOLICY FAMILY HEALTH AND SAFETY OF STUDENTS 649
POLICY FAMILY HEALTH AND SAFETY OF STUDENTS 649 Local Wellness Adopted 8/25/06 Amended 6/8/13 Context Federal Law (PL 108.265 Section 204) requires all schools to develop a local wellness policy and establish
More informationNavigating Standard 3.1
Navigating Standard 3.1 Annette Mercurio, MPH, MCHES City of Hope Duarte, CA Close Up is One Way to View It It s Helpful to Enlarge Perspective Standard 3.1 Patient Navigation Process A patient navigation
More informationDepartment of Transitional Assistance Transitional Aid to Families with Dependent Children Disability Supplement
Department of Transitional Assistance Transitional Aid to Families with Dependent Children Disability Supplement Do you need help to fill out the attached form? Call DTA at 1-877-382-2363. DTA can help
More informationPhysical Health Check: Guidelines for use
Physical Health Check: Guidelines for use Introduction Background People with mental health problems often have poor physical health. Their physical health needs often go unnoticed by mental health staff.
More informationPromoting Healthy Eating and Physical Activity in Health Care Settings
Promoting Healthy Eating and Physical Activity in Health Care Settings Prepared by: Sally Lawrence, MPH Lisa Craypo, MPH RD Sarah E. Samuels, DrPH Prepared for the Strategic Alliance December 2006 Samuels
More informationPatient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:
5002 Highway 39 N Bldg. A Meridian, MS 39301 Phone: 601-512-0500 Fax: 601-512-0505 Patient Information Patient: Gender: Male Female First Middle Last Primary Language: English Spanish Other Mailing Address:
More informationBeaumont Healthy Kids Program
Childhood overweight and obesity are increasing at an alarming rate. The prevalence has tripled over the past 3 decades. Overweight children are at risk for developing: Type 2 diabetes High cholesterol
More informationPressure Injury (Ulcer) Prevention
Patient & Family Guide 2016 Pressure Injury (Ulcer) Prevention Aussi disponible en français : Prévention des plaies de pression (FF85-1795) www.nshealth.ca Pressure Injury (Ulcer) Prevention Protecting
More informationSchool Wellness Policy. Physical Activity and Nutrition
Wellness Policies on Physical Activity and Nutrition School Wellness Policy On Physical Activity and Nutrition Montgomery County Youth Center 540 Port Indian Road Norristown, PA 19403 Purpose Montgomery
More informationADOPTED: 7/17/2018 REVISED: SCHOOL WELLNESS
TITLE: SCHOOL WELLNESS ADOPTED: 7/17/2018 REVISED: SCHOOL WELLNESS 1. Purpose The policy and its corresponding regulation have been created in compliance with federal and state requirements for establishment
More informationSTEUBEN COUNTY HEALTH PROFILE
STEUBEN COUNTY HEALTH PROFILE 2017 ABOUT THE REPORT The purpose of this report is to provide a summary of health data specific to Steuben County. Where possible, benchmarks have been given to compare county
More informationSonoma State University Department of Nursing Family Nurse Practitioner Program
1 Sonoma State University Department of Nursing Family Nurse Practitioner Program Pediatric Preceptor Packet N550ABC MEW 3/15 2 Department of Nursing 1801 East Cotati Avenue, Rohnert Park, California 94928-3609
More informationGlobal database on the Implementation of Nutrition Action (GINA)
Global database on the Implementation of Nutrition Action (GINA) Healthy Nutrition and Active Life Program of Turkey Published by: The Ministry of Health of Turkey, General Directorate of Primary Health
More informationBCBSM Physician Group Incentive Program
BCBSM Physician Group Incentive Program Organized Systems of Care Initiatives Interpretive Guidelines 2012-2013 V. 4.0 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee
More informationHealth Home Flow Hypothetical Patient Scenario
Health Home Flow Hypothetical Patient Scenario Client Background: Soozie SoonerCare Soozie is a single female, age 42, 5'6" tall 215 pounds. She smokes 2 packs of cigarettes a day. At age 24, Soozie was
More informationONTARIO COUNTY HEALTH PROFILE. Finger Lakes Health Systems Agency, 2017
ONTARIO COUNTY HEALTH PROFILE Finger Lakes Health Systems Agency, 2017 About the Report The purpose of this report is to provide a summary of health data specific to Ontario County. Where possible, benchmarks
More informationWHY THIS FORM IS IMPORTANT
Pediatric History Form Age 17 and under WHY THIS FORM IS IMPORTANT As a full spectrum Chiropractic office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought
More informationPayment Innovations HELP KEEPING YOUR COSTS IN CHECK
Blue Bulletin MEMBER NEWSLETTER Payment Innovations HELP KEEPING YOUR COSTS IN CHECK What s also in this issue: Need to Find a Doctor? We Can Help... Page 5 Make a Plan for Your Health... Page 7 bcidaho.com
More information4-H Youth Development Team Coordinator 4-H Community Educator
Wayne County 1581 Route 88N Newark, NY 14513 p. 315.331.8415 f. 315.331.8411 www.ccewayne.org Dear 4-H Families, Welcome to Wayne County 4-H! It is a very exciting time of the year to join 4-H; new projects
More informationDiocese of Harrisburg: School Wellness Policy Department of Catholic Schools Adopted: June 28, 2017 Revised: 1. Purpose
Diocese of Harrisburg: School Wellness Policy Department of Catholic Schools Adopted: June 28, 2017 Revised: 1. Purpose The vision for Catholic education in the Diocese of Harrisburg is one where the environment
More informationKern Health Systems Offers A New School Wellness Grant Program!
Kern Health Systems Offers A New School Wellness Grant Program! Background Kern Health Systems dba Kern Family Health Care is dedicated to improving the health status of our members through an integrated
More informationInternational Health Insurance Program. University of Missouri St. Louis
International Health Insurance Program University of Missouri St. Louis Action Items Create Aetna student health account Print Aetna insurance card Review plan details All on aetnastudenthealth.com/u msl
More informationDear Kaniksu Patient,
Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless
More informationEntering Private Practice or Primary Care in West Virginia: A Guide For Registered Dietitian Nutritionists
Entering Private Practice or Primary Care in West Virginia: A Guide For Registered Dietitian Nutritionists CO-AUTHORS: MEREDITH CHAPMAN & LACY DAVIDSON MAY 12, 2017 Objectives 1. Supplement the AND s Toolkit:
More informationWellness Screenings increase early detection and identification of chronic disease. Wellness Screenings and coaching may help improve health outcomes
Wellness Program Wellness Screenings increase early detection and identification of chronic disease. Wellness Screenings and coaching may help improve health outcomes and save lives for members and their
More informationNHS Greater Glasgow and Clyde Equality Impact Assessment Tool For Frontline Patient Services
NHS Greater Glasgow and Clyde Equality Impact Assessment Tool For Frontline Patient Services It is essential to follow the EQIA Guidance in completing this form Name of Current Service/Service Development/Service
More informationCarolinas Collaborative Data Dictionary
Overview Carolinas Collaborative Data Dictionary This data dictionary is intended to be a guide of the readily available, harmonized data in the Carolinas Collaborative Common Data Model via i2b2/shrine.
More informationFriday NITE Friends (Nursing in a Tender Environment)
Friday NITE Friends (Nursing in a Tender Environment) Custer Road United Methodist Church 6601 Custer Road, Plano, TX 75023 Phone Number: 972-618-3450 Application for Respite Services DATE OF APPLICATION
More informationhttp://www.bls.gov/oco/ocos077.htm Dietitians and Nutritionists Nature of the Work Training, Other Qualifications, and Advancement Employment Job Outlook Projections Data Earnings OES Data Related Occupations
More information1.2 ADULT CLIENT INTAKE FORM: Client Information
1.2 ADULT CLIENT INTAKE FORM: Client Information FOR OFFICIAL USE ONLY: Client Number Effective Insurance No OH No CLIENT INFORMATION Client name of significant other CHILDREN INFORMATION of birth of birth
More informationHealth and Wellbeing and You
Health and Wellbeing and You The Big Picture There is a clear link between healthy and happy staff and improved patient outcomes. As an organisation we wish to be world class. Therefore we are aiming
More informationYOUTH FOR TOMORROW NEW LIFE CENTER
APPLICATION N YOUTH FOR TOMORROW NEW LIFE CENTER CHRISTIAN ACADEMCY AND THERAPEUTIC BOARDING SCHOOL 2016-2017 Revised 7/1/2016 Child s Name: Step 1 Application Process Date Once we receive all of the information
More informationSURVEY Being Patient. Accessibility, Primary Health and Emergency Rooms
SURVEY 2017 Being Patient Accessibility, Primary Health and Emergency Rooms Being Patient: Accessibility, Primary Health and Emergency Rooms New Brunswick Health Council Who we are New Brunswickers have
More informationClient Information Form
Client Information Form Please read and complete all information requested. Date: Name: Address: City, State and Zip: Social Security Number: Home Phone: Work Phone: Cell Phone: E-mail: If client is a
More informationMedicare Annual Wellness Guide
Medicare Annual Wellness Guide 1 Background Established in 2010 through the Affordable Care Act, this benefit was designed to encourage monitoring of physical and cognitive abilities, as well as development
More informationAddress City, State Zip Code Phone
Email Correspondence Authorization Patient Name Date of Birth Address City, State Zip Code Phone By signing this form, I authorize Angela Pifer, Certified Nutritionist and 28 Day Health Solutions Co. (Angela
More informationPlease answer each question completely and return to NOHN as soon as possible. Once we have received your completed
Thank you for participating in your Medicare Annual Wellness Visit with North Olympic Healthcare Network as recommended by your primary care provider. Your provider understands that as we age our preventive
More informationStudents BP Student Wellness
Student Wellness The Governing Board recognizes the link between student health and learning and desires to provide a comprehensive program promoting healthy eating and physical activity for district students.
More informationAPPENDIX 2 NCQA PCMH 2011 AND CMS STAGE 1 MEANINGFUL USE REQUIREMENTS
Appendix 2 NCQA PCMH 2011 and CMS Stage 1 Meaningful Use Requirements 2-1 APPENDIX 2 NCQA PCMH 2011 AND CMS STAGE 1 MEANINGFUL USE REQUIREMENTS CMS Meaningful Use Requirements* All Providers Must Meet
More informationSouth Carolina Respite Coalition (SCRC) Respite Voucher Program
South Carolina Respite Coalition (SCRC) Respite Voucher Program What is respite (res-pit)? Respite is short, temporary breaks from providing hands on care for a loved one with a significant disability,
More informationProviderNews2015. a growing issue TEXAS. Body mass index and obesity: Tips and tools for tackling
TEXAS ProviderNews2015 Quarter 2 Body mass index and obesity: Tips and tools for tackling a growing issue For adults, overweight and obesity ranges are determined by using weight and height to calculate
More informationYouth Tomorrow New Life Center Application for Admission
Youth Tomorrow New Life Center Application for Admission 12 VAC 35-46-710 & 12 VAC 35-45-90 Child s : Date Step 1 Application Process Once we receive all of the information listed in this section, our
More informationSouth Dakota Health Homes Care Coordination Innovation
South Dakota Health Homes Care Coordination Innovation Senator Deb Soholt NCSL Health Innovation Task Force December 6, 2016 South Dakota Health Homes Health Homes (HH)- provide enhanced health care services
More informationApplication for Care PATIENT DEMOGRAPHICS HEALTHCARE. Whom may we thank for referring you to this office?
1 Application for Care Whom may we thank for referring you to this office? Today s Date: - - Please fill out these forms in their entirety so the doctors can deliver the highest level of care and get you
More informationSTANDARD OPERATING PROCEDURE. Servicing:
STANDARD OPERATING PROCEDURE Servicing: All transmitter batteries and bands are to be changed every 30 days (or if caregiver notifies agency of a dead battery) and replaced with a new battery and band,
More informationCommunity Service Plan Update: March 2015
Community Service Plan 2014-2016 Update: March 2015 John T. Mather Memorial Hospital 75 North Country Road, Port Jefferson, NY 11777 www.matherhospital.org Mather Hospital Activities Addressing NYS Prevention
More informationSANGER UNIFIED SCHOOL DISTRICT. Students WELLNESS
Board Policy SANGER UNIFIED SCHOOL DISTRICT BP 5030 (a) Students WELLNESS The Governing Board recognizes the link between student health and learning and desires to provide a comprehensive program promoting
More informationZooCrew Registration Packet Summer ZooCrew
Summer ZooCrew Check the weeks you would like to sign your child(ren) up for ZooCrew: 4 & 5 year olds* Week of 7/18 In My Backyard Week of 8/1 Once Upon a Story Week of 8/15 Where the Wild Things Are 6
More informationIf you require films or CD, kindly give us 48 hour notice or make technologist aware at the time of your study.
A Note to Our Patient: Your physician will be receiving a copy of your results via fax within two business days. Please contact your physician to go over your results and to obtain a copy of your report.
More informationLandstown High School Governors STEM Academy
Landstown High School Governors STEM Academy Step 1: Read and Sign Volunteer Guidelines and Ethics Agreement Sign this agreement once each year, at the beginning of the school year, or at the beginning
More informationBring your insurance card(s) and a picture identification card to your appointment.
Your appointment is on / / at :. Thank you for choosing Midwest Ear Specialists (a member of the BJC Medical Group) as your healthcare partner. We value communication, beginning with the new patient registration
More informationWelcome to University Family Healthcare, PA.
Welcome to University Family Healthcare, PA. We re delighted that you have chosen us as your primary care providers. We work hard to earn your trust and to see that you have the best healthcare possible.
More informationEmergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:
New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient
More informationStay Current. Our new website is easier to use. - Ease Your Back Pain - How to Save Money - Strong Bones for Life
SUMMER 2010 Stay Current Our new website is easier to use - Ease Your Back Pain - How to Save Money - Strong Bones for Life one TO one newsletter for medicare advantage members friends fly-fishing near
More informationMedicare Advantage Enhanced Benefits
Medicare Advantage Enhanced Benefits Fee Schedule: Revised November 30, 2017 Inclusion of a fee schedule amount for an item doesn t necessarily indicate coverage. Shaded cell indicates codes are no longer
More informationCoding Coach Coding Tips
An Independent Licensee of the Blue Cross and Blue Shield Association Coding Coach Coding Tips Medication Reconciliation Measure for Blue Advantage (November 2017) You can use Current Procedural Terminology
More informationSt. Mary s Health Professions Academy Student Application
St. Mary s Health Professions Academy Student Application Tenth and eleventh grade students in tri-state area who are interested in a health care career will be considered for the St. Mary s Health Professions
More information