PCW Program Forms & Resources

PCW Program Forms & Resources

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Forms & Resources

PCW Application Packet

Download our application packet for all the forms you will need when joining the PCW program. Forms include Attendance Policy, Client Commitment Form, Electronic Statement Authorization, Financial Policy, HIPPA Form, Initial Screening Physical Questionnaire, Patient Consent Form, PCW Enrollment Application, SMS Texting Consent Form, and Treatment Consent Form.

BMI Table

Body Mass Index chart based on height and weight.

Meal Replacement – Product Options

All of our meal replacement beverage flavors, snacks and bars!

Protected Health Information Policy

PCW’s policy on how your health information will be used.

Self Billing Forms

Use one of these forms if you are self billing your insurance company. Select the form for your doctor below.

Dr. Pam Burkhart
Dr. Jeff Crowell
Dr. Monica Duran
Dr. Susan Wu

Mandatory Attendance and Participation Policy

  • Clients are required to attend a weekly clinic/class session during the Reducing, Adapting, and Sustaining phases of the program.
  • Clients are expected to arrive on time for their scheduled clinic/class session.
  • During the Reducing and Adapting phases, clients will be allowed to miss no more than three (3) sessions. These absences include excused as well as unexcused absences. Clients missing more than three (3) sessions may be discharged from the program. Close medical supervision is essential.
  • When alternate arrangements need to be made due to schedule conflicts, the Physician’s Choice Wellness team must be notified at least 24 hours in advance. In an emergency situation, the center must be notified before the scheduled start of clinic/class session. In any case, the client is required to attend another session that week or early in the following week.
  • Clients should notify the team at least two (2) weeks before vacation so that arrangements can be made for additional products and appropriate counseling.
  • The sustaining phase is six (6) weeks long for the protocol of the program.
    Clients maintaining their weight within 5-10 lb of their goal weight after completing the sustaining phase will obtain lifelong beverage purchasing privileges.
  • In the event a private consultation with a counselor is scheduled, there will be an additional fee for this service.

ND1 & ND2 | LCP & VLCP | Program Enrollment Form

NDJV Program Enrollment Form

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