BARIATRIC SURGERY PROGRAM APPLICATION Updated: 1/2018 Page 1 of 6
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1 Updated: 1/2018 Page 1 of 6 Date: SELF Last Name: First: MI: Maiden: Home #: Cell #: Work #: Date of Birth: SSN#: Gender: Male Female Marital Status: Married Divorced Widowed Separated Never Married White Hispanic Asian Native American / Alaskan Native Race: African American Other: Employer: Current Weight: Current Height: YOUR PRIMARY CARE PROVIDER Physician: Phone: Fax: PRIMARY INSURANCE INFORMATION Primary Insurance Co: Policy Holder s Name: Relationship to Patient: Policy #: Group / Plan #: Customer Service Phone: Provider Inquire / Pre-Certification Phone: Contact Person: Is gastric bypass and/or lap-band for morbid obesity a covered benefit? If you have EVER had bariatric surgery, is REVISION SURGERY a covered benefit: SECONDARY INSURANCE INFORMATION Secondary Insurance Co: Policy Holder s Name: Relationship to Patient: Policy #: Group / Plan #: Customer Service Phone: Provider Inquire / Pre-Certification Phone: Contact Person: Is gastric bypass and/or lap-band for morbid obesity a covered benefit? If you have EVER had bariatric surgery, is REVISION SURGERY a covered benefit:
2 Updated: 1/2018 Page 2 of 6 AUTHORIZATION FOR RELEASE OF INFORMATION I authorize the physicians and outpatient staff in attendance on this case to release medical information to the pertinent insurance company(s) or third party carriers and request payment to be made directly to the billing entity. I understand that I am financially responsible for any balance not covered by the insurance carrier(s). I also request that payment of benefits from my policy be paid directly to the billing entity until otherwise notified. (Medigap/other) Signature: Signature of Parent (if minor): MEDICAL HISTORY TOBACCO PRODUCTS: Do you smoke? If NO, do you use any tobacco products? Have you EVER used tobacco products? If YES, what kind? How often? What year did you start? Quit date: ALCOHOL CONSUMPTION: How much of the following do you drink per week? Mixed Drinks (1oz/drink) Beer (12oz) Wine (6oz/glass) Do you have a history of alcohol abuse? Have you ever felt or been told that you have a drinking problem? ALLERGIES: Are you allergic to any drug, food or substance? If YES, list each allergy and reaction
3 Updated: 1/2018 Page 3 of 6 MEDICATION LIST: Medication Name Dosage Frequency Why do you take it? Use C-PAP or BI-PAP? Use OXYGEN? How many liters? Hours per day? SURGERIES: Date: Type of Surgery: Below, please indicate the location of any surgical incisions (scars from surgeries) that you have.
4 Updated: 1/2018 Page 4 of 6 ILLNESSES / MEDICAL CONDITIONS: Please mark all illnesses or medical conditions that you and/or your blood relatives have ever had: High Blood Pressure Diabetes High Cholesterol Cancer (list): Sleep Apnea Arthritis Heartburn / Indigestion / Reflux Angina / Chest Pain Heart Attack Depression / Anxiety Bleeding Problems Clotting Problems Polycystic Ovarian Syndrome You Mother Father Brother(s) Sister(s)
5 Updated: 1/2018 Page 5 of 6 INSURANCE DISCLAIMER FORM Many insurance companies have specific requirements that must be met before surgery is approved. The form below must be completed for all insurance companies except Medicare. It will help you to know and understand your benefits. Instructions: 1. Call the customer service number on your insurance card and speak to a customer service representative. 2. Tell the representative that you would like to check policy benefits for weight loss surgery for morbid obesity. 3. Read the questions below word for word to get the most accurate information. Please complete all questions and sign the form. 4. Fill out a form for each insurance company if you have more than one. Make as many copies as needed. Disclaimer: The Ohio State University Wexner Medical Center Bariatric Surgery Program is NOT responsible for incorrect information provided by the insurance company. Completion of this form does not mean that you are approved for weight loss surgery and does not guarantee payment for services. You will be responsible for any charges that your insurance does not cover Type in the information below BEFORE you call the insurance company Patient s Name: Patient s Date of Birth: Insurance Provider: ID Number: Group Number: Subscriber Name: Subscriber s Employer: Subscriber s Date of Birth: Insurance Company Name: Member Customer Service Number: Date Contacted: Name of Customer Service Representative: 1. Hello, my name is: I would like to learn about my plan benefits with regard to morbid obesity surgeries, including gastric lap band, gastric sleeve and gastric bypass surgery. Does my policy cover these services or is there an exclusion in my contract? (If there is an exclusion, the rest of the questions do not apply. Stop here!) 2. If you are applying for a revision surgery, ask: Do I have benefits in my policy for a revision of previous weight loss surgery? If yes, please verify specific requirements:
6 Updated: 1/2018 Page 6 of 6 3. Is The Ohio State University Wexner Medical Center in my network? 4. Are these surgeons in my network? Dr. Bradley Needleman: Dr. Sabrena Noria: 5. Does my policy cover services for associated surgery clearances such as cardiac, pulmonary, psychological evaluations and pre-admission testing? 6. If benefits are allowed, ask the following questions: What is the minimum BMI? If my BMI is Below 40, are there any co-morbidities that I must have to qualify for insurance approval? (Please list) 7. At what level does my policy pay for the following services. (For example 80%, 100%) % of Payment CPT Code Diagnosis Code 8. How much is my deductible? 9. What is my office visit co-payment? Open Revision E Gastric Lapband E Gastric Sleeve E Gastric Bypass E Do I need to complete a medical weight management program before surgery is approved? If yes, ask how long? 3 months 6 months 9 months 12 months 11. Does this program need to be supervised by a physician? If yes, please plan to make monthly appointments with your family doctor. Ask your doctor to include height, weight and recommendations for a diet and exercise plan in each visit note. Please note: Based on your clinical evaluations, an education program may need to be completed in addition to any insurance requirements. Patient Signature: Date:
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White
LONG ISLAND BARIATRIC, PLLC
PATIENT INFORMATION REFERRED BY: LAST NAME: FIRST NAME: MI: SOCIAL SECURITY # - - DATE OF BIRTH / / AGE MARITAL STATUS: Single Married Widowed Divorced Separated / SEX: MALE FEMALE ADDRESS APT # CITY STATE
Sidney P. Rohrscheib, M.D.
Sidney P. Rohrscheib, M.D. Thank you for your interest in the Illinois Bariatric Center. Should surgery be the best approach to managing your weight, we guarantee our commitment to personalized and quality
PATIENT INFORMATION. Caucasian or White Male Female. Unknown IN CASE OF EMERGENCY
Name (Last, First, Middle Initial): PATIENT INFORMATION Salutation: Mr. Social Security # Preferred Language: Race: Ethnicity: American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or
PATIENT QUESTIONNAIRE FORM
PATIENT QUESTIONNAIRE FORM PLEASE COMPLETE ALL SECTIONS OF PAPERWORK SECTION ONE: Patient information please verify that all info is correct and filled out in its entirety, i.e. work numbers, insurances,
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
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PATIENT REGISTRATION FORM
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PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY (518) PATIENT INFORMATION FORM
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WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU
DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY:
One Stop Medical Center Tel:
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PATIENT INFORMATION. DATE OF VISIT: Date of Birth Gender: M F. Address [Apt. # ] City State. address: Employer Phone
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PATIENT INFORMATION DATE OF VISIT: Date of Birth Gender: M F PATIENT FULL NAME: Address [Apt. # ] City State Zip Email address: Preferred Phone: Secondary Phone: Circle: Single Married Partnered Divorced
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PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
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PATIENT PROFILE PATIENT INFORMATION: Name: Date of Birth: Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed Address: City: Zip: Home#: Message#: Name of Primary Physician,
SKINNER FAMILY PRACTICE 1
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PLEASE ARRIVE TO THE CLINIC 30 MINUTES EARLY FOR YOUR APPOINTMENT
130 North Broadway Table Grove, IL 61482 Telephone: (309) 758-5070 Fax: (309) 758-5007 www.cmhospital.com Thank you for choosing Table Grove Community Medical Clinic for your Healthcare needs. We always
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number
PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone EMAIL Marital Status Single Widowed
Stark County Surgeons, Inc Patient Information. Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - -
Today s Date: / / Patient Information Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - - Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Other phone: ( ) - E-Mail
New Patient Medical Information Survey Revised 3/2013
New Patient Medical Information Survey Revised 3/2013 We are glad you chose the Augusta Surgical Group to meet your surgical needs. Please take a few minutes to fill out this form, as it will help us provide
COLLAR CITY PODIATRY
Richard Altwerger, DPM COLLAR CITY PODIATRY PATIENT INFORMATION FORM Timothy Fauler, DPM Name: Email PATIENT INFORMATION Date of Birth: Sex: M F Marital Status: City: State: Zip: Home Phone: Cell Phone:
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
PATIENT REGISTRATION FORM
CURRENT PATIENT INFORMATION -- PLEASE PRINT PATIENT REGISTRATION FORM EMPLOYMENT INFORMATION Patient Name: Employment (please circle): Full Time / Not Employed / Retired Address: Employer: City: State:
DRS. NUSSBAUM, LUNDBERG, ALTMAN & PICKETT David N. Nussbaum, DPM, Lori A. Lundberg, DPM Scott Altman, DPM & Scott Pickett, DPM WELCOME TO OUR OFFICE
DRS. NUSSBAUM, LUNDBERG, ALTMAN & PICKETT David N. Nussbaum, DPM, Lori A. Lundberg, DPM Scott Altman, DPM & Scott Pickett, DPM 35 Five Mile Woods Road 67 Prospect Avenue, Suite 140 Catskill, New York 12414
REGISTRATION FORM (Please Print)
Today s date: REGISTRATION FORM (Please Print) PATIENT INFORMATION PCP: Patient s Last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal
PATIENT REGISTRATION
PATIENT REGISTRATION Last / First / M.I. Patient Information Address / APT# City / State / Zip Phone # SSN: DOB Male Female Marital Status: Occupation Patient Email Address Assignment and Release I hereby
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION
HUNTSVILLE PEDIATRIC AND ADULT MEDICINE ASSOCIATES PATIENT INFORMATION Patient s Name Sex Male Female Date of Birth Address City/State Zip Code Home Phone Cell Phone E-mail address Driver License # Marital
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION GENERAL PATIENT INFORMATION (Please Print) Patient Name: of Birth: Sex: Male Female Marital Status: Single Married Divorced Other Street Address: Home Phone: City/State: Zip: Cell
Your appointment with our office is scheduled on
Grand Rapids OB/GYN Dr Stephen C Dalm Nisha McKenzie PA-C Erin Walker PA-C 5060 Cascade Rd SE Ste C Grand Rapids, MI 49546 Phone (616)247-1700 Fax (616)247-3679 www.grandrapidsobgyn.com Welcome to Grand
OUR POLICIES. Prior Authorization for prescriptions is $10.00 for each authorization completed.
OUR POLICIES Effective April 1, 2008, due to continued decreasing insurance reimbursements, we will begin strictly enforcing fees for certain tasks that we perform on behalf of our patients. Phone calls
Primary Insurance Company Subscriber s Name SSN# D.O.B. Secondary Insurance Company Subscriber s Name SSN# D.O.B.
Foot & Ankle Specialists of Marysville Carly Robbins, DPM Nicklaus Bechtol, DPM 388 Damascus Rd. Marysville, Ohio 43040 Phone: 937-578-4021 Fax: 937-578-4011 Patient Information Last Name: First Name:
Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
Patient Information & Health History Page 1. Date:
Patient Information & Health History Page 1 Patient Information Mr. Mrs. Ms. Dr. First Name M.I. Last Sex: Male Female Birth Date: Age Soc. Sec. # Address City State Zip Home Phone ( ) Cell Phone ( ) Email
Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext. Date of Birth: Sex: M F Social Security Number:
PATIENT INFORMATION Name: Last First M.I. Address: Street City State Zip Home Phone: ( ) ( ) ( ) Home Mobile Work ext Date of Birth: Sex: M F Social Security Number: Patient E-mail Address: Marital Status: