Verify Your Insurance

Information for Insurance Verification Form

Bariatric surgery is covered by most insurance companies, but your specific coverage is determined by your plan and the agreement between your employer and the insurance company. After you provide us with the information requested below, we will call your insurance company 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.

For more information on insurance coverage for weight loss surgery, click here.

Complete and submit the form below or download and fill out a printable version. Please feel free to contact our office with any additional questions.

Information for Insurance Verification Form

Full Name
Date of Birth
BMI Information
Address
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
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.

Surgery Information
Additional Information
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.