5149 N. 9th Ave Suite G32 Pensacola, FL phone fax

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Madison Bradley
5 years ago
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1 Dear Patient: Enclosed you will find the following items: 1. Patient Data Sheet 2. Medical Records Release 3. Program Fee Information 4. Manual Registration 5. Photo and Interview Authorization Please take a few minutes to fill out the included forms. This will greatly expedite the check-in procedure at your initial appointment. Please fill them out entirely, unless it is noted to be completed by office staff. Please note that some forms are two-sided. You will need to bring with you to your appointment: completed forms, your insurance card(s) and insurance authorization (if required by your insurance company) and a complete medication list with dosage information. Also, we are requesting a copy of your living will, if applicable. Be prepared to pay program fees and any co-pays or deductibles at this time of service. Please be aware that this office is considered a Specialist by your insurance company and this may require that you pay a different co-pay. Also, if you have had any diagnostic testing such as labwork, pap smear, mammogram, endoscopies, cardiac testing, etc., please obtain copies and bring them with you to your consultation. Also, please bring name, phone number, and address of your primary care physician, as well as information on any specialists that you see. Enclosed you will also find a map to the office. YOUR APPOINTMENT IS SCHEDULED AS FOLLOWS: Date: Time: Please arrive 45 minutes early. While everyone at the Sacred Heart Surgical Weight Loss Center loves children, we ask that you please make childcare arrangements prior to all appointments in our office. Please be aware if children are brought to appointments, you will be asked to re-schedule. We are sorry for any inconvenience this may cause. Please contact our office at (850) if you have any questions. Please bring a calendar with you.

2 Directions to Dr. Lord s office in Sacred Heart s Bariatric Clinic To help find our office with ease, enclosed is a map of the Sacred Heart Campus as well as printed directions to our office. We welcome your interest in our program and look forward to helping you through your weight loss journey. It is our desire to see each person at their scheduled appointment time. However, some surgeries require additional time which may delay the appointment for as much as an hour. Your patience is greatly appreciated. Please use the directions below to locate our office. Our office is located on the Brent Lane side of the hospital (same side as the Heart and Vascular Center) just prior to the intersection of Brent Lane and 9 th Ave. The driveway leading up to our building is situated between Dr. Ortega s Plastic Surgery Office and Lazy Boy Furniture. Our building number is 5149 which becomes visible as you reach the stop sign at the top of the driveway. There is a light blue awning over the side door of the building and there are five Bariatric Clinic parking spaces outside the side door with additional parking in the attached parking lot. If all spaces are filled, please park in the Brent Lane Parking Garage which is within walking distance of our office. We are located on the ground floor of Building 5149 (also known as the Payne Building) in Suite G-32. If you have any problems finding us, please call our office at for further directions.

3 PROGRAM FEE Patient Name: An administrative program fee of $ is due at the time of your initial visit with Dr. Lord. This fee is necessary to cover the time and resources of our clinic staff as we assist you through the Bariatric screening process prior to surgery. 1. Pre-surgery educational materials 2. Pre-surgery group meetings (support group/nutrition orientation) 3. Letter of medical necessity requested by and sent to your insurance company 4. Insurance verification and correspondence necessary for preauthorization 5. Review of previous medical records and diet history 6. Copy of Bariatric book 7. Nursing consults 8. Psychological evaluation 9. Nutritional evaluation 10. Remedy MD program Because this is an administrative program fee, it does not get billed to your insurance company. These fees are non-refundable and are not applied toward your out-of-pocket expense, including your deductible, co-pays, or any non-covered fees that you will be responsible for at the time of service. We cannot guarantee that your insurance company will approve you for Bariatric Surgery. We work closely with your insurance company to verify and assist you with meeting their requirements. However, it is also your responsibility to verify coverage for surgery as incorrect information may be given to our office. All records, data, diet information, etc. will be submitted to your insurance company by our office. Your insurance company determines your approval or denial status after a review of your entire record. I have read the above information and understand that I am responsible for the payment of $ at the time of my initial visit, and, prior to surgery, any balance due on all charges related to this weight loss surgery. Patient signature: Witness signature: Date: Date:

4 THE PHARMACY I WISH TO HAVE MEDICATIONS CALLED INTO IS: Pharmacy name: Pharmacy phone: Pharmacy fax:

5 Re: Authorization for Representation of Appeal Should my insurance carrier deny my request for surgery, I authorize Dr. Jeffrey Lord s office/office staff to appeal the denial on my behalf and act as my representative. Print Name Date Patient s Signature Date Witness Date OFFICE USE ONLY: Insurance Carrier s Reference Number: Patient s Insurance Policy Number:

6 RELEASE OF MEDICAL INFORMATION/RECORDS Before we can discuss your medical condition with anyone (spouse, children, significant other, etc.) We MUST have the following authorization on file. This list can be modified by the Patient, Parent, or Legal Guardian in writing only. The physicians of The Surgery Group and their staff have permission to discuss my medical condition, treatment, etc., and to release all information they have available to: Name: Name: Name: Name: Name: In case of emergency, call: Your address: Signature of Patient, Parent or Guardian: Date:

7 **THIS SECTION TO BE COMPLETED BY OFFICE STAFF** MEDICAL RECORDS RELEASE REQUEST DATE: TO: I hereby authorize the release of my medical records or specific items as listed: and request that they be transferred via : MAIL FAX to: Jeffrey Lord M.D. Sacred Heart Surgical Weight Loss Center 5149 N. Ninth Ave. Suite G32 Pensacola, FL Ph. (850) Fax (850) **THIS SECTION TO BE COMPLETED BY PATIENT** PATIENT NAME: PATIENT ADDRESS: PATIENT PH. NUMBER: PATIENT DOB: PATIENT SSN: PATIENT SIGNATURE:

8 5147 N. 9th Avenue Suite 325B Pensacola, FL phone fax 5149 N. 9th Ave Suite G32 Pensacola, FL Who is your Primary Care Physician? : Who referred you to our office? : Last Name: First Name: MI: Gender: M F Date of Birth: Social Security #: Street Address: City, State, Zip: Home Phone: Work Phone: Employer: Cell Phone: Race: Marital Status: Married Single Divorced Widowed What Insurance should be filed as your Primary Insurance Company?: Policyholder Name: Policyholder Date of Birth: Policyholder Social Security #: Relationship To Patient: Self Spouse Dependent Other: Policy #: Group #: Is this a group insurance policy? YES NO If YES, is the policyholder still employed? YES NO What Insurance should be filed as your Secondary Insurance Company?: Policyholder Name: Policyholder Date of Birth: Policyholder Social Security #: Relationship To Patient: Self Spouse Dependent Other: Policy #: Group #: Is this a group insurance policy? YES NO If YES, is the policyholder still employed? YES NO

9 5147 N. 9th Avenue Suite 325B Pensacola, FL N. 9th Ave Suite G32 Pensacola, phone FL fax I understand that I am responsible for payment of services rendered to me or my minor child. This includes any balance not paid by my insurance. I understand that The Surgery Group will file my insurance claim as a courtesy and that I will pay any amount not paid by insurance within 60 days. I understand that I must resolve any disputes with my insurance company. I authorize payment of insurance benefits directly to The Surgery Group for all services rendered. I authorize release of any medical or other information necessary to process these claims. If this account is in default, I agree to pay all collection of agency and attorney fees as well as court costs necessary to collect this debt. Signature of Patient, Parent or Guardian: Date: FILL OUT THIS SECTION IF THE PATIENT IS UNDER THE AGE OF 18: Parent Name: Address, if different: City, State, ZIP:

INSURANCE INFORMATION

INSURANCE INFORMATION PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language: