Weight Loss Surgery Insurance Worksheet
This form is designed to clarify if your insurance policy covers weight loss surgery and to highlight any specific prerequisites required for surgery approval. We kindly ask you to fill out this form fully before your scheduled consultation. We recognize that understanding insurance details can be challenging, so please don't hesitate to contact our office with any questions. After your consultation, our team will coordinate with your insurance provider to verify the information you've provided.
Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Call The Customer Service Phone Number On Your Insurance Card
Questions for the Representative the Following
Do I have coverage for bariatric surgery? - Lap Band CPT 43770 - Sleeve Gastrectomy CPT 43775 - Gastric Bypass CPT 43644 - Diagnosis: Morbid Obesity E66.01
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Yes
No [there is a plan exclusion. If the rep tells you no,then bariatric surgery was excluded from your insurance plan by the EMPLOYER/HR DEPARTMENT. You can verify the information is correct by checking with HR or your employee benefit book.Please call the office at 773 365 1300 and notify us of a plan exclusion. We will double check this for you]
Do I have to go to any special distinction or insurance certified centers?
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No
Yes [must go to a _______________________ certified center. Call our office at any time 773 365 1300 to notify us of this requirement. Our affiliated hospital is nationally accredited program, Blue Distinction and Aetna Institute of Quality].
Do I have to complete any sort of pre- operative diet or nutrition requirement? And if yes, for how long?
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No
Yes [for __________ months. If this is your requirement we have all of the resources to help you collect the appropriate documentation and get surgery approved. Do not let this deter or scare you, it is a common step in this process and a requirement of many insurance companies].
Is there anything else on the medical policy I need to be aware of?
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Rep’s Name:
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Call reference #:
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Please Call The Office At 773 365 1300 With Any Questions. We are More Than Happy to Assist You.
This worksheet is for patient use only. Completion does not guarantee coverage or approval for weight loss surgery. Having the benefit for weight loss surgery does not mean you are approved for the procedure. Our staff will request approval for surgery once your insurance medical policy criteria has been met. The AMITA Health team will verify benefits after consultation to confirm accuracy of this information .
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