FAX Recommendation Form

Fax to Can Do program at 952-925-1276

Patient Name:___________________________________________________________

DOB:_____________ Weight___________ Height____________ BMI___________

Home Phone # _____________________________________

Work Phone # _____________________________________

_________________________________is essentially healthy« and will benefit

patient name

from moderate exercise and dietary interventions using acceptable diets.

« please attach medication list

__________________________________________ ___________________

Provider signature Date

__________________________________________

Clinic

The confidential information accompanying this transmission contains protected health information under state and federal law and is legally privileged. This information is intended only for the use of the individual or entity named above and may be used only for carrying out treatment, payment or other healthcare operations. The recipient or person responsible for delivering this information is prohibited by law from disclosing this information without proper authorization to any other party, unless required to do so by law or regulation. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please destroy the materials and contact us immediately by calling the department number listed above. No response indicates that the information was received by the appropriate authorized party.

Form #510013e, Aug 2002