***REFERRING PROVIDERS FORM***

Patient Information
Patient Name*

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Insurance (please note we only accept the insurances listed)*
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Patient Status*
Please note that Blue Shield only accepts the following preventive codes. Select any of these codes that apply to maximize your patient's benefits and reduce out-of-pocket costs.*

E88.819 Insulin resistanceE88.81 Metabolic syndromeE88.811 Insulin resistance syndrome, type AE88.819 Insulin resistance, unspecifiedE88.818 Other insulin resistanceE78.2 Mixed hyperlipidemiaE78.3 HyperchylomicronemiaE78.41 Elevated lipoproteinE78.49 Other hyperlipidemiaE78.5 Hyperlipidemia, unspecifiedE78.6 Lipoprotein deficiency
Please choose all diagnosis codes that apply*

Prediabetes: R73.03Impaired fasting glucose: R73.01Type 2 diabetes: E11.9Type 1 diabetes: E10.9Gestational diabetes mellitus in pregnancy: O24.419Cardiovascular: I25.10 (for coronary artery disease)Gastrointestinal disease unspecified: K52.9Chronic kidney disease unspecified: N18.9Essential hypertension: I10Hyperlipidemia (unspecified): E78.9Coronary artery disease: I25.10PCOS (Polycystic Ovary Syndrome): E28.2Anorexia nervosa: F50.0Bulimia nervosa: F50.2Binge eating disorder: F50.8Eating disorder unspecified: F50.9Abnormal weight loss: R63.4Abnormal weight gain - not during pregnancy: R63.5Underweight: E46"Obesity" (BMI of 30): E66.9"Overweight" (BMI of 25.0 to 29.9): E66.3Other
Is the Patient on insulin?*
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Pertinent Medications

Insurance Info
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Referring Provider
Referring Provider Name*

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Referring Provider Phone*
Referring Provider Fax*
Referring Provider NPI*
Referring Provider Email*
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Please confirm that you have an ROI for us to reach out to this client.*

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We do not service this state.

Unfortunately, we do not offer services in this state at this time. We'd still be happy to collect the patient's information in case we expand in the future.
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