Division of Bariatric & Minimally Invasive Surgery

LifeBridge Health

Division of Bariatric & Minimally Invasive Surgery

5401 Old Court Rd.

Randallstown, MD 21133

(410) 701-4880

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 informational seminars, which we hold at Sinai Hospital’s Zamoiski Auditorium and Northwest Hospital Pike Conference Room. 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 (http://www.lifebridgehealth.org/bariatricsurgery) or call 1-866-404-DOCS (3627).

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 Sinai Hospital, Northwest Hospital, or Dorsey Hall location in Columbia. Adherence to the program greatly increases your success following bariatric surgery. All program locations adhere and teach the same nutritional information concerning food choices and surgery.

Prior to being seen at one of the LifeBridge Health centers, 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 and Northwest Hospital locations. We only accept cash or checks at our other locations.

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.

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, but these tests will be ordered on an individual basis after you have met with one of the surgeons. If you have any questions about the Bariatric Surgery Program at Sinai Hospital, 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 Celine Richardson, MD, FACS

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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
Anacin
Ascriptin
AsperDrink
Aspergum
Aspirin/Butalbital/Caffeine
Aspirin with buffers
Aspirtab
Aspir-Trin
Bayer
BC Powder
Bismuth Subsalicylate (Pepto Bismol, Kaopectate, Bismatrol, Kola-Pectin, Diotame, Kapectolin, Bismate, Bismakote, Bismuth, Stomach Relief, Kao-Tin, Kensorb, Kao-Paverin, Peptic Relief, Sootheze).
Bufferin
Butalbital
Carisoprodol Compound
Citrated/Aspirin/caffeine
Cope
Damason-P
Easprin
Fiorinal / Aspirin Products:
Ecotrin
Endodan
Equagesic
Excedrin
Gelprin
Genacote
Goody’s Halfprin
Orphenadrin P-A-C
Magnesium Salicylate
Magnaprin
Micrainin
Miniprin
Norgesic (Forte)
Norwich Aspirin
Pamprin
Percodan
Robaxisal
Soma
St. Joseph’s Aspirin
Synalgos-DC
Trilisate
Vanquish
Zorprin
Store brands: Good Neighbor Pharmacy, Good Sense, Leader, Medi-First, Quality Choice, Top Care, Rite Aid, etc. / NSAIDS products:
Diclofenac (Flector, fcatafrlam, Voltaren, Arthrotec, Cataflam, Cambia)
Disflunisal (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, Prevacle 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)

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Application Process

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

2.  Complete the Patient Application on pages 5 - 15 and the Nutritional Assessment on pages 16 – 22.

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 (see enclosed flyer for dates).

PLEASE INCLUDE COPY OF DRIVER’S LICENSE AND INSURANCE CARD (FRONT & BACK) WITH APPLICATION!

Additional Information

·  HMO'S, POINT OF SERVICE, AND MANAGED CARE PLANS:

If your insurance company is an HMO, point of service, or managed care plan, you must obtain a written out-of-network referral before your consult with the surgeon. You must follow the rules of your insurance company in order to obtain the highest level of benefits. Your primary care physician's office will need to contact the insurance company for a referral. You may make an appointment with the surgeon; however, the referral must be received or brought with you to the appointment.

·  SELF PAY PATIENTS:

If your insurance does not cover gastric bypass surgery and you wish to proceed as a cash patient, please contact the office for fees and scheduling information.

·  PROGRAM FEE:

A program fee is required at your initial appointment. This fee is non-refundable and covers 1 year of unlimited visits or consultations with the nutritionist.

·  PAIN MEDICINE:

Do not take any “pain medication/anti-inflammatories” three weeks prior to surgery without consulting with your surgeon (see list on page 2). Most pain medicines increase the chance of bleeding. This may result in cancellation of your procedure.

IMPORTANT NOTICES

We only accept cash or credit card as acceptable form of payment.

We require 24 hour notice if you are unable to keep your scheduled appointment. A fee of $25 will be billed to you for each missed appointment.

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: r HMO / r POS / r PPO / r MCO / r Medicare / r Other: ______
Policy No.: ______ / Group No.: ______ / Effective Date: ______
Ask your insurance representative the following questions:
1.  Is this a small group policy? / r Yes r No
2.  Does this policy have ANY exclusion for Bariatric Surgery or Morbid Obesity? / r Yes r No
3.  Does the insurance cover the following procedures:
a.  Gastric Bypass (CPT 43644)
b.  Gastric Banding (CPT 43770)
c.  Sleeve Gastrectomy (CPT 43843) / r Yes r No
r Yes r No
r Yes r No
4.  Is this procedure subject to any pre-existing conditions on the policy? If yes, please list ______ / r Yes r No
5.  Are there specific criteria that need to be met in order to qualify for this surgery? If yes, please list:
a.  Total months of consecutive supervised weight loss
b.  Other: ______ / r Yes r No _____ months
5.  Do you need a referral from your Primary Care Physician to see a Specialist? / r Yes r No
6.  Is there a co-pay to see the surgeon?
a.  What is the co-pay? / r Yes r No
$ ______
7.  Do you have a deductible?
a.  What is the amount?
b.  How much of the deductible has been met? / r Yes r No
$ ______
$ ______
Please include a copy of your driver’s license and insurance card (front & back) with the application

Patient Application

NAME: ______Date: ______

I am interested in seeing: / I am interested in having: / What is your preferred location?
Dr. Christina Li / Gastric Bypass / Northwest
Dr. Celine Richardson / Laparoscopic Band / Sinai
Sleeve Gastrectomy / Ellicott City
Social Security No.:
First Name: / Middle Initial:
Last Name: / Gender: / M r F r
Applicant’s Maiden Name:
Birth Date: / Current Age:
Weight: / Height: / BMI:
Mother's Maiden Name: / ______

Insurance Information:

Primary Insurance / Secondary Insurance
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:

NAME: ______

Contact Information:

Home Address:
City: / State: / Zip:
E-mail:
May we contact you at this number?
Home Number: / Yes r / No r / Preferred r
Cell Number: / Yes r / No r / Preferred r
Work Number: / Yes r / No r / Preferred r
Employed: / Yes r / No r / Full Time r / Part Time r
Employer: / Occupation:
Employers Address:
Length of time @ current employment: ______Years ______Months

Emergency Contact Information:

Name: / Relationship:
Home Address: / City, State, Zip:
Home Number: / Cell Number:
Work Number:

Pharmacy Information:

Pharmacy Name: ______ / Phone Number: ______
Location: ______ / Fax Number: ______
r Family/Friend
r Insurance
r Internet / r Magazine
r Newspaper
r Primary Care Physician / r TV
r Other: ______

I heard about LifeBridge Health Bariatric through:

NAME: ______

Primary Care Physician / Other Physician
Name:
Specialty:
Address:
Address 2:
City:
State:
Zip:
Phone Number:
Fax Number:

Physician Information:

Social History:

Marital Status:
r Single
r  Married
r  Divorced
r  Separated
r  Widowed / Ethnic Origin:
r  Black/African American
r  Hispanic
r  White/Caucasian
r  Asian/Oriental
r  Other: / Education:
r  9 to 11 years
r  High School Graduate
r  Vocational/Technical
r  Attended College
r  College Graduate
r  Post Graduate Degree / Number of Children:
r  None
r  1
r  2
r  3
r  4
r  5 or more
Religion:
r  Atheist
r  Catholic
r  Jehovah Witness
r  Jewish
r  Presbyterian
r  Other: / Do you currently or have you ever use/d tobacco products?
If yes, what kind:
r  Cigarettes
r  Cigars
r  Chewing tobacco / Yes r No r
If yes, how much:
r 1/2 pack or less per day
r  Between 1 – 1.5 packs per day
r  Between 1.5 – 2 packs per day
r  2 packs or more per day
Do you drink alcohol? Yes r
If yes, how much:
r  Less than 2 per day
r  Between 2 – 5 per day
r  Between 6 – 10 per day
r  More than 11 per day / No r
If yes, how often:
r  Daily
r  Weekly
r  Monthly
r  Occasionally / Do you use illegal drugs? Yesr
If yes, what kind:
r  Marijuana
r  Cocaine
r  Heroin
r  Amphetamines / No r
If yes, how often:
r  Daily
r  Weekly
r  Monthly
r  Occasionally
List the diets/programs have you tried within the last 5 years:
Diet or Weight Loss Medication / Year / Length in Months / Number of Pounds Lost
What age were you considered obese?
What was your lowest adult weight?
What is your desired weight?

Check if you have used the following medications to lose weight:

r  Phentermine
r  Phen-Fen / r  Orlistat (Xenical)
r  Meridia / r  B-12 shots
r  Other

Check the eating behaviors which have contributed to weight gain:

r  Skipped meals / r  Frequent sweets / r  Vomiting after large meals
r  Large portions / r  High carbohydrate diet / r  Frequent snacking
r  Fatty foods / r  Binge eating / r  Fast foods
r  Emotional eating / r  Laxative use / r  Other:

NAME: ______

Drug Allergies: r Check if no allergies

Medication Allergies / Type of reaction

Current medication (prescription and non-prescription): r Check if no medications

Medication / Strength / Frequency / Purpose / Started
(Initials /Date) / Stopped (Initials /Date)

NAME: ______

Medical History (a all that apply):

r  Anxiety / r  DVT (Leg Blood Clots) / r  Peripheral Edema
(Swelling of the legs)
r  Arthritis / r  Fibromyalgia / r  Pneumonia
r  Asthma / r  Heart Attack / r  Pulmonary Embolism
r  Bronchitis / r  High blood pressure / r  Reflux Disease
(Heartburn or severe indigestion)
r  Cancer / r  Hypercholesterolemia
(High cholesterol) / r  Seizure
r  Cardiac Surgery / r  Hypertriglyceridemia
(High triglycerides) / r  Sleep Apnea
Diagnosedr Observedr
r  Chest Pain / r  Hyperthyroidism / r  Snore
r  CHF / r  Hypothyroidism / r  Stress Incontinence
r  Depression / r  Leg Ulcers / r  Stroke
r  Diabetes Type I
(Insulin dependent) / r  Lower back pain / r  Varicose Veins
r  Diabetes Type II (Non-Insulin Dependent) / r  Migraines/Headache / r  Other:

Surgical History (a all that apply): r Check if no surgical history