Healthy Non-Surgical Weight Loss

Co-Management Physician Agreement


PHYSICIAN CONTACT INFORMATION

     

, CA    

    

PRACTICE CONTACT INFORMATION

 

   

CO-MANAGEMENT SERVICES AND PAYMENT

Consultation: Complete the Thinner You Centers Co-management consultation form for any patients recommended for the program and forward to Thinner You Centers via fax or email. 

Follow Up: Provide patient with one follow up visit 7-14 days after balloon insertion.  The follow up may occur in person or via telephone.  Please complete the Thinner You Centers Follow up note form and forward to Thinner You Centers via fax or email.

Co-management Payment: Compensation of $500 will be paid within 30 days of balloon insertion and completion of the consultation and follow up care for any patient for which co-managed care is provided by physician.

Dietary Counseling: For practices offering dietary counseling for patients, they must agree to provide monthly counseling sessions each month for 12 months following the balloon insertion.  Counseling must be provided by a registered dietitian or nutritionist.

Counseling Payment: Total payment of $750 will be paid to the practice

AGREEMENT

By signing this agreement physician agrees to the terms and conditions of the Co-Management Agreement available at www.thinneryoucenters.com/co-managementagreement, as though such terms were fully set forth herein and requests inclusion as a Thinner You Centers Affiliate.

 

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Signed by Chris Gangnes
Signed On: January 11, 2018

Healthy Non-Surgical Weight Loss https://thinneryoucenters.com
Signature Certificate
Document name: Co-Management Physician Agreement
Unique Document ID: 0854abcc5b66a58e937a8be17d7848337b4c2d82
Timestamp Audit
January 11, 2018 3:39 pm PDTCo-Management Physician Agreement Uploaded by Chris Gangnes - chris@thinneryoucenters.com IP 64.58.170.235