::: AUSTIN INSTITUTE OF BARIATRICS & LAPAROSCOPY :::



	Medical History Form

	Insurance Coverage for Surgery

	HIPPA privacy notice

Would you like to know if your Health Insurance covers "Weight Loss Surgery"?

Please fill out the following form. AIBL staff will call your Insurance company, verify benefits and will call you back.

Instructions:

1. Please fill out all the fields adequately. All fields are required.

2. Please list all Insurance companies even if they don't cover weight loss surgery. If you don't have secondary insurance please type "None" in the fields.

3. Please allow us 4 - 5 business days to respond back. AIBL staff will call you to explain the benefits and additional details.

Last Name
First Name
Date of Birth
Primary Phone number
Additional phone number
Mailing address
Email address
How did you hear about us
Procedure interested in
Policy holder
Relationship to policyholder
Name of Primary Insurance company
Insurance company phone number
ID or Policy number
Group number
Name of Secondary Insurance company
Insurance company phone number
ID or Policy number
Group number
Comments