Co-Management Form

Co-Management Program Form

This form will allow us to setup your practice as a co-manager of balloon care and receive remuneration for services rendered.
  • PHYSICIAN CONTACT INFORMATION

  • 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. 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
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