FIRST TIME QUESTIONNAIRE

First Time Questionnaire Form

Provider Information

Provider First Name *

Provider Last Name *

Provider DEA Number *

Provider Email *

Provider Phone *

Provider Fax *

Member First Name *

Member Last Name *

Member Date of Birth *

Member Employer Employee ID

Member Dependent Number

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) *

Does the patient have Hyperlipidemia, Hypertension, Obstructive Sleep Apnea, Cardiovascular disease, Type 2 diabetes, Nonalcoholic fatty liver disease/MASH, Osteoarthritis of knee/hip/back, Moderate/Severe Asthma or Reactive airway disease? *

Has the patient completed 3 health coaching sessions within the past 6 months? *

Please read the following information prior to completing this form.

This form is for providers or the St. Luke's Wellness team only. Please do not fill this form out if you are an employee.
Submit the initial eligibility questionnaire for a patient who is new to the GLP-1 Benefit Program. Required before a patient can participate or receive reimbursement.
For Provider Email - please enter the email which will be used for communications regarding the approval decision. For St. Luke's Wellness team, please use team inbox.
Member ID + Person Code (2-digit) person code is required to accurately identify the member.