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

First Name *

Last Name *

Date of Birth

Month *

Day *

Year *

BMI Information

Height

Weight

Contact Information

Street Address *

Street Address (continued)

City

State

Zip

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 Surgery Information section.

Primary Insurance Information

Primary Insurance Company

Subscriber Name

Subscriber Date of Birth

Subscriber ID Number

Insurance Company Phone 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

Insurance Company Phone Number

Surgery Information

Procedure interested in: * Weight Loss SurgeryRevision Weight Loss SurgeryOther, please note in message area below

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

Information for Insurance Verification Form

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