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Insurance

INSURANCE

Many weight loss surgical procedures are covered by health insurance. When planning for your surgery it is important to determine if your specific health insurance plan covers weight loss surgery. Please be aware that every plan is different and benefits are constantly changing. Unfortunately not every plan has weight loss surgery coverage. Our staff of insurance experts will acquire the necessary information and help you through the process of getting approved for your procedure.

Please fill in the information below for your
free insurance evaluation.

You will be contacted as soon as we receive benefit information from your insurance company.

CONTACT INFORMATION

First Name:

Last Name:

Address:

City:

State:

Zip:

Daytime Phone Number:

Evening Phone Number:

Cell Phone Number:

Email:

Confirm email:

INSURANCE INFORMATION

Policy Holder's Employer:

Insurance Company's Name:

Member's Policy Number:

Group Number:

Insurance Phone Number (on back of card):

Insured's Last Name:

Insured's First Name:

Date of Birth:

Once we have obtained benefit information, we will contact you within 48 hours: If you are not available, may we leave a message?

Yes

BARIATRIC PROCEDURE INFORMATION
Please check off the laparoscopic bariatric procedure/procedures you are interested in.

Adjustable Gastric Banding

Roux-en-Y Gastric Bypass

Gastric Sleeve

Revisional Bariatric Surgery

Stomaphyx

Band over Bypass

Single Incision Bariatric Surgery

PLEASE FILL IN THE FOLLOWING INFORMATION THAT WILL ENABLE US TO DETERMINE YOUR BODY MASS (BMI) which is the measurement required to check on your eligibility for bariatric surgery.

Gender: Male Female

Weight: lbs.

Height: ft. in.

Age:

How did you hear about us?:

If you have any questions please call us
toll free at 877-659-0011

ATTEND A FREE WEIGHT LOSS SEMINAR
Our weight-loss seminars are the best place to learn more about bariatric procedures and have our surgeons answer any questions and help alleviate any fears you may have.

Find a Free Seminar or call toll free 877-659-0011

FAIRFIELD COUNTY BARIATRICS & SURGICAL SPECIALISTS, P.C. has been recognized as a Center of Excellence® for Bariatric Surgery

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to learn why patients should select a Center of Excellence® for their weight loss surgery

BMI CALCULATOR

PROCEDURES

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