Metabolic & Bariatric Laparoscopic Surgery

Information Request Form

Name

E-mail

City

State

Age

My treatment will be paid for by: Insurance Self pay

Weight

Insurance

Individual Group

Height

Insurance provider type: HMO PPO POS

EPO Medicare other or don't know

If you want us to check whether your insurance will cover the surgery comple this section:

Name of Insured Person:

Primary Insurance Provider:
(or "don't know")

Insurance provider type:

HMO	PPO	POS
EPO	Medicare other or don't know

Relationship of Insured
Person to Patient:

Insured Person's Date of Birth:

Insured Person's Employer:

Insured Person's
Subscriber ID#:

Group/Policy/Other#:

Customer Service Phone
Number on Insurance Card:

Would you like to speak with one of our patient consultants:

YES

What is the best time and phone number to reach you at between the hours of

9:30 am - 5:00 pm

Contact Phone
Cell Phone

Date

Hours

Which procedure would you like more information about?
Your Surgery might be covererd by Insurance:

		Lap-Band		Revision of failed previous surgery
		Gastric Bypass (Roux-en-Y)		Other (specify)
		Gastric Sleeve Procedure

Comments:

How did you find this Website?

Internet Search

Friend/Recommendation Name

Magazines