Co-Management 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
Physician Name*
First Name Last
Physician Mobile Phone*
Physician Email*
Enter Email Confirm Email
Practice Name
Practice Address
Street Address Address Line 2 City ZIP / Postal Code
Practice Phone
Website
PRACTICE CONTACT INFORMATION
Practice Contact Name
First Last
Practice Contact Title
Practice Contact Phone
Practice Contact Email
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

PHYSICIAN CONTACT INFORMATION