Get the free Prior Bariatric Surgery Referral Form - Alberta Health Services

Last Name First Name Prior Bariatric Surgery Referral Birthdate PhD# (yyyy-Mon-dd) Fax completed form along with all required information to 780.735.6669 Only complete for patients who have had prior

How to fill out prior bariatric surgery referral

How to fill out prior bariatric surgery referral:

1. Obtain a copy of the referral form from your healthcare provider or bariatric surgery center.
2. Provide your personal information, including your name, date of birth, address, and contact details.
3. Fill in your insurance information, including the name of your insurance company, policy number, and any required authorization or pre-certification numbers.
4. Include the details of your primary care physician, including their name, contact information, and any relevant medical records or test results.
5. Provide a brief medical history, including any previous weight loss attempts, related medical conditions, and current medications or allergies.
6. Describe your reasons for seeking bariatric surgery and include any relevant documentation, such as a letter of medical necessity from your healthcare provider.
7. Attach any supporting documents, such as previous consult notes, dietary counseling records, or psychological evaluations.
8. Submit the completed referral form to your healthcare provider or bariatric surgery center, following any specific instructions provided.

Who needs prior bariatric surgery referral:

1. Individuals who are considering or have been recommended for bariatric surgery by their healthcare provider.
2. Patients who have met the necessary criteria for bariatric surgery, as determined by their healthcare provider and insurance company.
3. Individuals whose insurance company requires a prior referral for bariatric surgery coverage.

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What is prior bariatric surgery referral?

A prior bariatric surgery referral is a formal request for approval from an insurance company or healthcare provider before a patient can undergo weight loss surgery. It ensures that the patient meets the necessary medical criteria and guidelines for the procedure.

Who is required to file prior bariatric surgery referral?

Typically, the healthcare provider or surgeon who evaluates the patient for bariatric surgery is responsible for filing the prior referral on behalf of the patient to the insurance company.

How to fill out prior bariatric surgery referral?

To fill out a prior bariatric surgery referral, the healthcare provider must complete a designated referral form that includes patient information, medical history, details of the recommended surgery, and justification for the procedure, along with any necessary documentation and signatures.

What is the purpose of prior bariatric surgery referral?

The purpose of a prior bariatric surgery referral is to ensure that the patient qualifies for the surgery according to medical necessity guidelines set by insurance providers, and to obtain pre-authorization for financial coverage of the procedure.

What information must be reported on prior bariatric surgery referral?

Information that must be reported on a prior bariatric surgery referral includes the patient's demographic details, medical history related to obesity, previous weight loss attempts, the specific bariatric procedure recommended, and pertinent clinical findings supporting the need for surgery.