MEMBER INSTRUCTIONS (Follow these steps).
Step 1: Attend 6 Shape Your Life group classes at an
assigned CalOptima site. Have the instructor
complete the Instructor Section of this form to
conrm your attendance at all 6 group classes.
Step 2: Visit your doctor within 120 days after
completing the last Shape Your Life class. At
the visit, have your doctor complete the Doctor
Section of this form and fax it to CalOptima.
If you qualify, it will take at least 8 weeks after we receive
the completed form for you to receive your no-cost $50
gift card.
Member Name:
Date of Birth:
CalOptima ID Number:
Mailing Address:
City, State, Zip:
Phone:
CalOptima Assigned Site:
Instructor Name (printed):
Instructor Signature:
BMI at Initial Assessment:
Date of Follow-up Visit:
BMI at Follow-up Visit:
Provider Name (printed):
Provider Signature/Stamp:
Provider TIN:
Phone:
PROVIDER (DOCTOR) INSTRUCTIONS
■ The provider follow-up visit must be completed within
120 days after the member has attended his or her
6th Shape Your Life class.
■ Provide healthy weight counseling to the member
and, if needed, provide ongoing care related to
healthy weight.
■ You must sign or stamp this form for the member
to receive the no-cost $50 gift card.
■ Your oce needs to fax this form to CalOptima
at 714-338-3120. Or mail it to CalOptima Health
Management department at 505 City Parkway West,
Orange, CA 92868.
INSTRUCTIONS FOR SHAPE YOUR LIFE INSTRUCTOR
Please sign this form after the member has completed a
minimum of 6 group classes.
Class Dates
1 4
2 5
3 6
This form must be lled out and signed by the Shape Your Life
class instructor and your doctor to receive the no-cost $50 gift card.
Disclaimer: You must meet all health reward eligibility requirements to qualify for the gift card. Kaiser members
are excluded. It takes at least 8 weeks after we receive the completed form to process your gift card. The gift
card cannot be used to purchase alcohol, tobacco or rearms. Gift card has no cash value, and CalOptima is not
responsible if it is lost or stolen. You may only receive 1 gift card every 12 months for this health reward. Gift cards
are available while supplies last. This health reward may be discontinued at any time without notice.
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