UB Transition Patients

UB Other Patient (Transition, etc)
This form allows you to give a patient platform access, and is specifically for patients who've already started their progress to surgery OR those whose insurer is not listed. If you are unsure, you can always use this form. It will be processed manually by the VHP team. Please leave any notes you want.

The patient will be invited to the correct package, based on the information you provide here. Thank you.
Patient Name*

First NameLast Name
Patient Email*
Patient Phone
Expected Date of Surgery

MonthDayYear
Date
Insurer*

Aetna (1 Nutrition Appt)Aetna (3 Nutrition Appts)BCBS ALBCBS Anthem, BCBS EmpireBCBS ARBCBS CABCBS CapitalBCBS ExcellusBCBS Federal Group 101-109BCBS Federal Group 110-116BCBS Florida/Highmark PA/MA/ID, Scott & WhiteBCBS Horizon NJBCBS IndependenceBCBS MI/CareFirst MD, UHC, Meritain HealthBCBS MNBCBS NCBCBS Regence/PremeraBCBS SC, Tricare (prime-select)BCBS TX, IL, OK, NMCignaHealth Select TXMedicareUHC Railroad and SAIA Truck DrivingOrbera + Nutrition
Insurer*
Total number of pre-op RD appointments REQUIRED*
Total number of pre-op RD appointments COMPLETED*
Name of Person Submitting Form*
Any other notes for VHP team, that will help us enroll this patient in the correct package?
Should be Empty:

UB Other Patient (Transition, etc)