New Patient Verification Form

New Patient Verification Form

Completing this form will allow our team to verify your insurance coverage prior to your consultation. Someone from our team will reach out within the next business day to discuss next steps.
Personal Information
Patient Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date-of-Birth*

MonthDayYear
Date
Gender(sex at birth)

MaleFemale
Preferred Language
Medical Information
Height(ft)*
Height(in)*
Weight(lbs)*
Height Total Inches
BMI Calculated
Have you had previous weight loss surgery?*

YesNo
Surgeon Preference*
Insurance & Financial Information
Will you be using insurance?*
Primary Insurance*
Primary Insurance Policy Number*
Primary Insurance Group Number
Employer of Insured Party
Provider Service Phone Number
This phone number is located on the back of your insurance card.
Policies Acknowledgment
By marking below you are acknowledge consent and understanding of the below terms.*

I agree that any medical records obtained for determination of qualification for surgery will not be returned to me if I am not a candidate for surgery.I authorize KC Bariatric, LLC to release my personal and confidential information to my health insurance carrier for the purpose of verifying my coverage, benefits, payment information and researching coverage criteria &/or requirements.I authorize KC Bariatric, LLC to contact me via phone, text message, or email using the contact information I provided above.
Patient or Authorized Representative Signature*

Clear
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Questions or additional information.
Upload Insurance Card(front & back)

Uploading a copy of your card will help us verify insurance coverage.
Cancelof
Should be Empty:

New Patient Verification Form

Personal Information

Medical Information

Insurance & Financial Information

Policies Acknowledgment