PowerPlayMD Submission Form


		The Power to P.L.A.Y. Promoting Lean and Active Youth

"The Power to P.L.A.Y."
Promotion Lean and Active Youth...
A Medical Weight Loss Revolution for Children
Ph: (310) 289-8242 Fax: (310) 289-8248

YOU MAY CALL THE NUMBER, SUBMIT ONLINE, OR FAX IN THIS FORM.
Please also request an Initial Consultation, 99245, directly from the patient's insurance.
Now Available for Adults!

*Please fill out form, items in red are required
Child's Name:
Child's Date of Birth:
Name of Parent or Guardian:
Address:
City, State, Zip Code:
Telephone Number:
Type of Insurance: Health Plan / IPA / ID #:
PLEASE ATTACH A COPY OF THE PATIENT'S INSURANCE CARD.
Date of Most Recent Visit:
Weight: Height:
Latest BP Measure:
Medical/Psychological problems:

*Please Check appropriate diagnosis box
	Diagnosis	ICD-9

	Abnormal Weight Gain	783.1
	Acanthosis Nigrans	701.2
	Asthma	493.9
	Back Pain	724.6
	DM Type 1	250.03
	DM Type 2	250.03
	Eating Disorder	307.50
	Elevated Blood Pressure	796.20
	Family History of DM	V18.0
	Gynecomastia	611.1
	Hidden Penis	752.65
	Hyperinsulinism	251.1
	Hyperlipidemia	272.4
	Morbid Obesity	278.01
	Polyphagia	783.60
	Sleep Apnea	V21.0
	Stunted Growth	272.1
	Other Diagnosis:

	Clinic Information:

Name of Referring Physician/P.A./R.N./Teacher:

Signature:

Lydie Hazan, M.D.
PowerPLAY
5800 Wilshire Blvd. Los Angeles, CA 90036
310-289-8242 phone ~ 310-289-8248 fax
www.powerplaymd.com