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Bariatric Surgery Request PROVIDER INFORMATION PROVIDER NAME PROVIDER NPI FAX NUMBER TELEPHONE NUMBER CLIENT INFORMATION CLIENT NAME PROVIDER ONE CLIENT ID SERVICE REQUEST INFORMATION SURGERY DESCRIPTION

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What is bariatric surgery request?

Bariatric surgery request is a formal application requesting approval for bariatric surgery, which is a weight loss surgery for individuals with obesity.

Who is required to file bariatric surgery request?

Individuals with obesity who are seeking approval for bariatric surgery are required to file the bariatric surgery request.

How to fill out bariatric surgery request?

To fill out a bariatric surgery request, individuals need to provide their personal information, medical history, previous weight loss attempts, and other relevant details as requested.

What is the purpose of bariatric surgery request?

The purpose of bariatric surgery request is to seek approval for weight loss surgery for individuals with obesity to improve their health and quality of life.

What information must be reported on bariatric surgery request?

Information such as personal details, medical history, BMI, previous weight loss attempts, and any other relevant medical information must be reported on the bariatric surgery request.

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