Verify Your Insurance

Complete and submit the form below, and our team will provide a quick turnaround to verify if your insurance covers bariatric surgery. Please note that at this time, we have opted out of participation in Medicare and Medicaid.

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Information for Insurance Verification Form

Full Name

First Name *

Last Name *

Date of Birth

Month *

Day *

Year *

BMI Information

Height

Weight

Contact Information

Phone *

Email *

Self-Pay Patients

Please mark this box if you do NOT have insurance.

If you mark this box, you will be a self-pay patient with our office. Skip insurance fields and move on to the "Services Interested In" section.

Primary Insurance Information

Primary Insurance Company

Subscriber Name

Subscriber Date of Birth

Subscriber ID Number

Secondary Insurance Information

Please mark this box if you are covered under a secondary insurance plan.

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 Benefits

Information for Insurance Verification Form

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