RENEWAL QUESTIONNAIRE

Renewal Questionnaire Form

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 *

Has the patient maintained 5% weight loss in baseline body weight after 6 months on medication? *

Override First Time Questionnaire Requirement? (Optional)

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

This form is for providers only. Please do not fill this form out if you are an employee.
Submit the renewal questionnaire for a patient continuing in the GLP-1 Benefit Program. Required to renew eligibility and maintain program participation.
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.