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Get Wv Unicare Weight Watchers Print Out Form

The Get Up and Get Moving! family workbook (for children ages 6 to 12 and their families)? Yes No Name of Referring Provider (please print) Signature NPI Number Date Provider Phone Number If the patient is under 18 years of age, a parent/legal guardian s consent is required for enrollment in a weight management program. This does not apply to emancipated minors. Parent or Guardian s Full Name (please print) Parent or Guardian s Signature Date Program Qualification (to be completed.

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