Patient Forms

Consultation Paperwork and Health History Forms

• 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 - 23. You must return the form titled "Understanding Risks and Complications" and the Pre-Operative Patient Health History forms before we can schedule your first pre-operative clinic appointment. You can return them to us by fax at 410-550-1822 or by email to bariatrics@jhmi.edu. 
  
  
• 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
  This form must be completed by a licensed psychologist or psychiatrist. 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. To make an appointment with Janelle W. Coughlin, Ph.D., our psychologist, please call 410-550-8803.
  
  
• Scheduling Your Nutrition Appointments
  
  
• 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.
  
  
• Patient Follow-Up Form
  Please complete this information ONLY if you have already had your surgical procedure. Please complete this information for each follow-up visit.
  

Post-Operative Nutrition Information

• Gastric Bypass
• Laparoscopic Adjustable Band
• Duodenal Switch
• Sleeve Gastrectomy
• StomaphyX™
• Protein Supplements
• Vitamins

CPT Codes

• 43846 - Open R-n-Y Gastric Bypass
• 43644 - Laparoscopic Gastric Bypass
• 43770 - Laparoscopic Adjustable 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
• 43999 - StomaphyX™