Verify Your Insurance

Bariatric surgery is covered by most insurance companies, but your specific coverage is usually determined by your plan and the agreement your employer has with the insurance company. Please provide us with the information below and we will call your insurance to verify if weight loss surgery is a covered benefit under your plan. At this time we have opted out of participation in Medicare and Medicaid.

In order to get the most accurate information, please also call the number on the back of your insurance card to verify your benefits. Please note the name of the person you spoke with, the date and time of your call, the criteria that must be met in order to achieve coverage for bariatric surgery, and which procedures are covered. For more information on insurance coverage of weight loss surgery, click here.

Please feel free to contact our office  with any additional questions. 

 
PATIENT INFORMATION
Name *
Date of Birth *
Gender *
Height *
This information is used to calculate your BMI to verify eligibility for weight loss surgery.
Weight *
This information is used to calculate your BMI to verify eligibility for weight loss surgery.
Address *
Address 2 *
City *
State *
Zip Code *
Select a Country *
Primary Phone *
Is this your *
Secondary Phone *
Is this your *
E-mail *
Preferred method of contact: *
Spouse/Partner's Name *
Spouse/Partner's Date of Birth *
SELF-PAY PATIENTS *
If you mark this box, you will be a self-pay patient with our office. Skip insurance fields and move on to the Surgery Information section.
PRIMARY INSURANCE INFORMATION
Primary Insurance Company *
Subscriber Name *
Subscriber Date of Birth *
Subscriber ID Number *
Plan *
Group Number *
Insurance Company Phone Number *
Please provide provider services/customer service number, not your member services number.
SECONDARY INSURANCE INFORMATION
*
If you have a secondary insurance, please fill out the information below. If not, skip this section and move on to the Surgery Information section.
Secondary Insurance Company *
Subscriber Name *
Subscriber Date of Birth *
Subscriber Address *
Subscriber ID Number *
Plan *
Group Number *
Insurance Company Phone Number *
Please provide provider services/customer service number, not your member services number.
SURGERY INFORMATION
Procedure interested in: *
Revision Patients: Please note your original bariatric surgery *
How did you hear about us? *
Would you like to be added to our mailing list? *
Please provide any additional information here: *
Electronic Signature
I authorize my physician to release to my insurance company or any other third party, in order to determine my eligibility for any procedure and my liability for payment, any information including diagnosis and records of such treatment as necessary to obtain reimbursements for services rendered. I request and authorize my insurance companies to pay directly to my physician the amount due in my pending claim for surgical and/or medical care.
*
Date *