Insurance Verification for Weight Loss Surgery

Please note that we do not currently participate in Medicare or Medicaid.

CareCredit offers flexible financing options to help patients manage healthcare expenses over time—learn more or apply today.

Primary Insurance Information

Primary Insurance Company

Subscriber Name

Subscriber Date of Birth

Subscriber ID Number

Insurance Phone Number

Upload Insurance Card (Optional)

Secondary Insurance Information

If you have a secondary insurance plan, 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 ID Number

Services Interested In

Revision Patients: Please note your original bariatric surgery information.

Additional Information

How did you hear about us?

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 *

Verify Your Insurance

Information for Insurance Verification Form

Verify Your Insurance

Information for Insurance Verification Form

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