Weight management referral form - Scott and White Health Plan - swhp 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Referring Provider's printed name, phone number, fax number, email address, and NPI or SWID# in the designated fields.
3. Fill in the patient's information including their name, date of birth (DOB), address, city, state, zip code, home phone number, daytime phone number, and insurance ID number.
4. Complete the cardholder's name and DOB if applicable. Then provide current height, weight, goal weight, and ideal weight in the respective fields.
5. Document any medical history such as arrhythmias and input vital statistics like blood pressure, pulse rate, cholesterol levels (including HDL and LDL), triglycerides, serum creatinine, potassium levels, uric acid levels, and A1c if diabetic.
6. Finally, ensure that the provider signature and date are filled out before submitting the form along with any required documents to Scott and White Health Plan Pharmacy via fax.

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