Email Preferences

By registering for this event, you agree to receive email confirmation and event reminders. Registration emails may contain confidential information. If you want to receive messages through our secure system, please uncheck this box and you will be asked to create an account and take extra steps to view these emails.

Personal Information

Billing Information

Additional Information

READ THIS AGREEMENT IN FULL

By submitting this form, you begin the registration process. A Way to Wellness representative will contact you to complete and confirm your registration. For questions about this paperwork or registration, call 801-507-2400 or email waytowellness@imail.org.

Privacy Notice:

Way to Wellness follows HIPAA guidelines to protect your personal and health information. For secure communication, use the encrypted Intermountain Health App. If you don’t have a MyHealth account, we can help you create one.

I watched the Way to Wellness Information Video: *

Program Overview

The Way to Wellness Program is an evidence-based program designed for adults 18 and older to meet health and disease prevention goals. The Way to Wellness Information video and this program agreement provide details on requirements and expectations.

12-Month Program Includes:

• 20 group sessions (90 minutes each)

• 3 individual sessions (60 minutes each) with a registered dietitian

• Two guaranteed make-up sessions

Program Goals:

• Attend all 23 sessions and actively participate

• Complete at least 150 minutes of moderate physical activity each week

• Track and submit food intake and physical activity weekly

• Make lasting lifestyle changes

• Lose 5-7% of your starting weight by the program’s end

Outcome Measures:

• Confidential weigh-ins at each group session (or remote weight reporting)

• Additional health measures may be taken at individual sessions

Cost:

• Varies based on insurance, scholarship, or self-pay options

• Participants without insurance may qualify for a scholarship, depending on eligibility and availability

• Intermountain Health offers a 30% self-pay discount

• No refunds for self-pay participants after starting the program

Insurance Coverage:

• Participants are responsible for verifying insurance coverage

• We can bill using these CPT codes: S9449 (Group Weight Management Class), 0403T (Diabetes Prevention Program), G9887 (Medicare Diabetes Prevention Program)

Medicare and SelectHealth Coverage

• Medicare Part B and Medicare Advantage cover the program for participants with certain health conditions (e.g., BMI ≥25, prediabetes)

• Most SelectHealth and EMI plans cover the program

• Participants must complete all 23 sessions for insurance coverage

Scholarship Participants:

• Scholarships are available based on eligibility. To qualify, you must meet specific criteria.

Participant Health History

Please fill out the following information to the best of your ability. Include only diagnosed conditions.

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Eating Disorder Disclaimer

To schedule a dietitian specializing in disordered eating, call 801-507-3253.

Am I ready for Way to Wellness?

Please consider the following questions before committing:

Are you comfortable interacting in a group setting? *
Are you willing to track your food intake? *
Are you willing to work up to 150 minutes of moderate physical activity per week? *
Are there any upcoming life events that could prevent you from completing the program? *
Are you planning to become pregnant, are pregnant, or breastfeeding in the next year? *

Thank you for your interest in Way to Wellness!

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