Sinai Hospital of Baltimore Division of Bariatric Surgery ...

Sinai Hospital of Baltimore Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

Dear Patient:

Thank you for inquiring about our weight loss surgery program! The decision to undergo weight loss surgery is not a decision you made quickly; in a similar fashion, the process of preparing you for surgery also cannot occur quickly, nor be rushed. Please take the time to fill out the enclosed intake form carefully and completely. Remember to attach a legible copy of your picture ID along with your medical insurance card (front & back). Our staff will then contact you to give you an appointment date, usually within two weeks of receipt of your application.

In the meantime, we encourage you to attend our monthly informational seminars and/or webinars. We will be present at each seminar, as well as, members from our staff and post-op patients. Everyone is invited to attend, be sure to verify the dates on our website at or call (410) 601-4486.

Most insurance companies require that policy holders be seen monthly for 3-6 consecutive months to document weight loss attempts and progress. Therefore, as an insurance and program requirement we require patients to see the Registered Dietitian at either Sinai Hospital or Chartwell Professional Center. Adherence to the program greatly increases your success following bariatric surgery. Both programs adhere and teach the same nutritional information concerning food choices and surgery

Prior to being seen at Sinai Hospital or Chartwell Professional Center ask your Primary Care Physician (PCP) for a request for consultation. If a referral is required with your insurance plan, please make sure we have an updated referral on file. All co-payments are due at the time of service. PLEASE NOTE we only accept cash, Visa, and/or MasterCard for payment at Sinai Hospital. We only accept cash or checks at Chartwell Professional Center.

Your insurance plan will likely require extensive testing to ensure that they will approve the surgery. If you prefer, you can obtain some of this BEFORE your initial consultation. The following are required by ALL insurance companies of all patients prior to scheduling surgery: 1) Proof of attendance at a minimum of one of our bariatric seminars or webinars. 2) A letter from your primary care physician. This letter should summarize your diet history, your obesity-

related medical problems and any physician-supervised weight loss attempts that you have had. It should also include a sentence or two stating that your physician feels that you are a good candidate to undergo surgery. 3) Psychology/psychiatry clearance. All patients are required to undergo a psychological evaluation prior to surgery, so that we can document adequate knowledge of the procedure, reasonable weight loss expectations, and the ability to comply with the rigorous dietary restrictions post-operatively. You can obtain clearance from your own psychologist or psychiatrist if you prefer.

Every patient will require additional pre-operative testing, these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about Sinai Hospital's Bariatric Surgery Program and our locations, please contact us at 410 601-4486 and one of our staff will be glad to help you.

We look forward to meeting you and helping you reach your goal of a healthy weight and healthier lifestyle.

Christina Li, MD, FACS, Division Head

410-601-4486 (office) 410-601-9014 (fax)

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Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore

Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

****KEEP THIS PAGE***

AVOID these medications 2 weeks prior to surgery and call the

office before taking any new medication for pain management

Aspirin Products:

Aggrenox Alka-Seltzer (Effervescent pain reliever and antacid, lemon-lime effervescent pain reliever and antacid, extra strength effervescent pain reliever and antacid, Morning relief) Anacin (maximum strength) Ascriptin (enteric regular strength, regular strength, arthritis pain) AsperDrink Aspergum Aspirin/butalbital/caffeine Aspirin with buffers Aspirtab Aspir-Trin Bayer (Children's Chewable, Adult Low Strength, Genuine Bayer, regular strength caplets, women's aspirin plus calcium caplets, extra strength back and body pain) BC Powder (arthritis strength) Bismuth Subsalicylate (Pepto Bismol, Kaopectate, Bismatrol, KolaPectin, Diotame, Kapectolin, Bismate, Bismakote, Bismuth, Stomach Relief, Kao-Tin, Kensorb, Kao-Paverin, Peptic Relief, Sootheze) Bufferin (arthritis strength, extra strength) Carisoprodol Compound (with codeine) Citrated/Aspirin/caffeine Cope Damason-P Easprin

Aspirin Products:

Ecotrin (Adult Low Strength, Maximum Strength) Ecprin Endodan Entercote Equagesic Excedrin (extra-strength, migraine) Fiorinal Fortabs Gelprin Genacote Goody's (body pain formula powder, extra strength headache powders, extra strength pain relief tablets) Halfprin Orphenadrine P-A-C analgesic Magnesium salicylate (Doan's, Backprin, Keygesic, Momentum, Agesic, Mobidin, Novasal, Pamprin) Magnaprin (Improved, arthritis strength) Micrainin Miniprin Norgesic (Forte) Norwich Aspirin Pamprin Percodan Robaxisal Soma Stanback Powder St.Joseph (Adult Low Strength chewable, Adult Low Strength enteric coated tablets) Store brands (Good Neighbor Pharmacy, Good Sense, Leader, Medi-First, Quality Choice, Top Care, Rite Aid)

Synalogos-DC Trilisate Vanquish Zorprin

NSAIDS products:

Diclofenac (Flector, fcataflam, Voltaren, Arthrotec, Cataflam, Cambia) Diflunisal (Dolobid) Etodolac (Lodine) Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Ibuprofen (Advil, Motrin, Genpril, Haltran, Menadol, Midol, Vicoprofen, Dristan) Indomethacin (Indocin) Ketoprofen (Oruvail, Orudis) Ketorolac (Toradol, Acular, Acuvail, Sprix) Meclofenamate Mefenamic (Ponstel) Meloxicam (Mobic) Nabumetone (Relafen) Naproxen (Naprosyn, Prevacie Napra PAC, Aleve, Naprelan, Anaprox) Oxaprozin (Daypro) Piroxicam (Feldene) Salsalate (Disalcid, Amigesic, Salflex, Persistin, Mono-gesic, Marthritic, Arthra-G, Argesic-SA) Sulindac (Clinoril) Tolmetin (Tolectin)

Cox-2 Inhibitors

Celecoxib (Celebrex)

410-601-4486 (office) 410-601-9014 (fax)

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Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

****KEEP THIS PAGE****

Application Process

1. Call your insurance company and complete the Insurance Verification form on page 4.

2. Complete the Patient Application on pages 5 - 13 and the Nutritional Assessment on pages 15 ? 18.

3. Return the Insurance Verification, Patient Application, and the Nutritional Assessment to our office (pages 4 ? 18). a. Please keep the folder & resource papers in the right sleeve.

4. Our office staff will verify your insurance benefits.

5. One of the physicians will review your application.

6. Our office staff will call you to schedule an initial appointment with the physician and dietitian. a. Reminder: the nutritional consultation has a mandatory program fee (not covered by any insurance) which is due at the initial appointment. b. All self-pay portions are due at the time of service. c. We accept only cash or credit cards as payment. We do not accept checks.

7. Please allow 1-2 weeks, plus mailing time for our staff to contact you.

8. While waiting to hear from our office you can complete the following steps: a. Contact your Primary Care Physician for any necessary referrals per your insurance requirement. (Some offices require 1-2 weeks notice to have referrals ready). b. Attend one of our bariatric seminars/webinars (see enclosed flyer for dates).

410-601-4486 (office) 410-601-9014 (fax)

3

Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore

Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

Please include copy of driver's license and insurance card (front & back) with application

410-601-4486 (office) 410-601-9014 (fax)

4

Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore

Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

Insurance Verification Form

Call to verify insurance coverage for bariatric surgery. The telephone number is located on the back of your insurance card. This completed form must be submitted with your application.

First Name:

Middle Initial:

Last Name:

Birth Date:

Insurance Company:

Insurance Phone No.:

Date Insurance Company Called:________________________ Spoke with:_____________________

Type of Plan:

HMO

POS PPO

MCO

Medicare

Other: _________________

Policy No.: __________________ Group No.: ________________ Effective Date: _____________

Ask your insurance representative the following questions:

1. Is this a small group policy?

Yes No

2. Does this policy have ANY exclusion for Bariatric Surgery or Morbid Obesity?

Yes No

3. Does the insurance cover the following procedures:

a. Gastric Bypass (CPT 43644) b. Gastric Banding (CPT 43770) c. Sleeve Gastrectomy (CPT 43775)

Yes No Yes No Yes No

4. Is this procedure subject to any pre-existing conditions on the policy? If yes, please list _______________________________________________________

Yes No

5. Are there specific criteria that need to be met in order to qualify for this surgery? If yes, please list:

Yes No _____ months

a. Total months of consecutive supervised weight loss

b. Other: __________________________________________

5. Do you need a referral from your Primary Care Physician to see the

specialist?

Yes No

6. Is there a co-pay to see the Specialist? a. What is the co-pay?

7. Do you have a deductible?

Yes No $ ___________

Yes No

a. What is the amount?

$ _________

b. How much of the deductible has been met?

$ _________

Please include a copy of your driver's license and

insurance card (front & back) with the application

410-601-4486 (office) 410-601-9014 (fax)

5

Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore

Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

Patient Application

NAME: _________________________________

Date: __________________

I am interested in having:

-CHOOSE A PROCEDURE -

Gastric Bypass

Sleeve Gastrectomy

Laparoscopic Band

I am interested in seeing the doctor & dietitian:

-CHOOSE A LOCATION -

Sinai Hospital ? Baltimore, MD

Chartwell Professional Center ? Elkridge, MD

First Name: Last Name:

Social Security No.:

Birth Date:

Weight:

Height:

Mother's Maiden Name:

Contact Information: Home Address:

City:

E-mail:

Home Number:

Cell Number:

Work Number:

Employed:

Yes

Employer: Employers Address:

BMI:

Middle Initial:

Gender: M

F

Current Age: (If known)

State:

Apt/Unit #: Zip:

May we contact you at this number?

Yes

No

Preferred

Yes

No

Preferred

Yes

No

Preferred

No

Full Time

Part Time Retired

Disabled

Occupation:

Length of time @ current employment: ________ Years ________ Months

410-601-4486 (office) 410-601-9014 (fax)

6

Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore

Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

NAME: _________________________________

Emergency Contact Information: Name: Home Address: Home Number: Work Number:

Relationship: City, State, Zip: Cell Number:

Pharmacy Information:

Pharmacy Name: ________________________________________________________________

Address: ______________________________ City, State, Zip: ________________________

Phone Number: ________________________ Fax Number: ___________________________

Physician Information:

Name: Specialty: Address: Address 2: City: State: Zip: Phone Number: Fax Number:

Primary Care Physician

Other Physician

410-601-4486 (office) 410-601-9014 (fax)

7

Web Site: E-mail: bariatric@

(updated on 4/19/2013)

Sinai Hospital of Baltimore

Division of Bariatric Surgery

Hoffberger Building, Suite #15 2435 West Belvedere Avenue

Baltimore, MD 21215

NAME: ________________________________

Insurance Information:

Insurance Carrier Name: Group Number: ID Number: Policyholder's Name: Policyholder's DOB: Policyholder's SS#: Relationship to Insured: Insurance Address: City, State, Zip: Phone Number: Fax Number:

Primary Insurance

Secondary Insurance

I heard about Sinai Bariatric through:

Family/Friend

Magazine

Insurance

Newspaper

Internet

Primary Care Physician

TV Other:

410-601-4486 (office) 410-601-9014 (fax)

8

Web Site: E-mail: bariatric@

(updated on 4/19/2013)

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