Application Date: MM-DD-YYYY  
First Name: *
Last Name: *
How did you hear about the PEIA Weight Management Program?
Gender: *
If you are female, are you currently pregnant?
*
Date of Birth: * MM-DD-YYYY
Current Weight:   * pounds  
Current Height: * feet  inches     
Waist Circumference:   * Inches
BMI Score Calculation:    
Do you have PEIA PPB insurance?
     *
Have you ever participated in the PEIA Weight Management Program?
     *
Have you ever had bariatric surgery (lap band or gastric bypass)?
      
If you have had bariatric surgery in the past how many years ago did you have the procedure?
 
Are you considering having bariatric surgery?
      
What is the incident or trigger that prompted you to join the program?
Social Security Number: *
Primary Cardholder SSN: *
Primary Cardholder PEIA ID:
*
PEIA ID Numbers should start with 770.
Where do you currently work?
Are you a medicare recipient?
Mailing Address: Street: *
City: * State: * Zip: *
County:
Email:  
For the phone numbers below please list only the numbers where you would be willing to take our calls.
Home Phone:
Work Phone:
Mobile Phone:
We will need to reach you for scheduling appointments or other administrative tasks during the hours of 9:00 AM to 5:00 PM. What is the best method to reach you for these appointments?



This program includes telephone health behavior counseling sessions of 15-30 minutes approximately every 45 days that may require privacy. These calls will likely occur between 12 PM & 8 PM, Monday through Thursday. How do you prefer to be contacted for these sessions?


What day(s) of the week do you prefer to be contacted for these sessions?



What time during the day would you prefer to be contacted for these sessions?




    
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