Empower Insurance / Financial Worksheet

SEMINAR DATE:

Date

Please complete this form with your personal/insurance information. We will check your insurance benefits for weight loss surgery. We will contact you with that information as soon as your insurance benefits have been verified.

Patient Name (Please Use Full Name) :*

Phone #:*

Primary Care Provider:

DOB*

DOB

SSN

Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance:*

Secondary Insurance:

Policy Holder’s Name:*

Secondary Policy Holder’s Name:

Policy Holder’s DOB:*

Secondary Policy Holder’s DOB:

Primary Policy #:*

Secondary Policy #:

Primary Group #:

Secondary Group #:

Provider/Customer Service Number:(Found on back of Insurance card)

Secondary Provider/Customer Service Number:(Found on back of Insurance card)

Employer:*

Secondary Employer:

PLEASE LET US KNOW WHICH ONE YOU ARE INTERESTED IN BY CHECKING THE APPROPRIATE BOX:

Surgical Weight Loss

Gastric BypassGastric SleeveRemoval of Lap BandConverting to Alternate Procedure

Non-Surgical Weight Loss

Have You Had Previous Bariatric Surgery?

Gastric BypassLap BandGastric SleeveOther

WHAT IS YOUR ESTIMATED BMI:

**We provide this insurance benefit coverage information in good faith based on the information you and your insurance company has provided to us. Estimates can change if any of the varibales change, including but not limited to: changes in the benefits or coverage your plan provides; changes in your health plan's contract with BMH; accuracy of any information supplied by you; other claims you may make against your health plan concurrently with your participation in the BMH bariatric program; your plan year starting over prior to time of service, resetting the deductible and co-pay assumptions on which this estimate is based; any unexpected complications that may arise; and/or BMH's base charges for BMH bariatric program participation changin after the estimate is given. This is not a guarantee of cost or coverage in any way.**

Please inital the following:

This is NOT a guarantee of payment or coverage *

Understand the YOU must contact your insurance to verify benefit coverage, and if information is different than provided above, let us know. *