 | | 
|
|
- New Patient Packet
This packet contains a presentation on the potential risks and complications of surgery and a pre-operative patient health history. Please read the presentation, sign the form titled "Understanding Risks and Complications," and complete the Pre-Operative Patient Health History.
IMPORTANT:
Print pages 12 - 24. You must bring the form titled "Understanding Risks and Complications", the Pre-Operative Patient Health History forms, and the HIPAA research database release form to your first pre-operative clinic appointment.
- Maryland Uniform Consultation Referral Form
If your primary care physician does not have a standard referral form, please use this one. Please remember that we cannot accept a note on a prescription pad as a referral.
- Psychological Evaluation Form
If your psychological evaluation will be performed by an outside psychologist or psychiatrist, please have him or her complete this form. Please be certain that your surgeon will accept an evaluation from an outside psychologist or psychiatrist
- Insurance Benefits and Requirements Form
Does your insurance plan have a benefit for bariatric surgery? What are your insurance company's requirements? If you don't know, our partner can research these things for you. Complete this two-page document to the best of your ability and return it to your surgeon's medical office coordinator or our financial coordinator at your consultation appointment.
- Follow-Up Patient Packet
Please complete this information ONLY if you have already had your surgical procedure. Please complete this information for each follow-up visit.
- 43846 - Open R-n-Y Gastric Bypass
- 43644 - Laparoscopic Gastric Bypass
- 43770 - Lap Band
- 43845 - Biliopancreatic Diversion with Duodenal Switch
- 43659 - Unlisted Laparoscopic Stomach Procedure; use for Sleeve Gastrectomy and pair with 43845 to denote a laparoscopic Biliopancreatic Diversion with Duodenal Switch
| | | |
