Insurance Verification Request Form

							Lap-Band® Reimbursement Solutions Hotline
1-800-Lap-Band Option 3 (Phone)  1-800-711-0810 (Fax)
SERVICE REQUEST FORM

Required:    Do you have your patient’s written consent to release patient identifiable information for the purpose of
             conducting insurance research?
                        Yes        No (If no, obtain consent from patient before forwarding this request.)
             Has the patient been clinically evaluated for LAP-BAND surgery?
                        Yes        No (If yes, please indicate clinical information such as BMI, and Co-Morbid conditions below.)


                         Patient Name: _____________________________________      M/F (please circle)
                         Date of Birth: ___________________ Social Security Number: _________________
      Patient            Address: _______________________________________________________________
    Information          City, State, Zip: _________________________________________________________
                         Phone: _______________________ Fax: ___________________________________
                         Height: _______________ Weight: _____________ BMI: ___________________


                         Surgeon Name: Darin M. Minkin________________________________________
                         Tax ID#: 56259 2570__________           Specialty: Surgery-General, lap, and bariatric
                         Site Name: Darin M. Minkin, D.O._________________________________________
      Surgeon            Office Contact Name: Jill_________________________________________________
                         Address: 2325 Dougherty Ferry Road      Suite 104____________________________
    Information          City, State, Zip: St. Louis, MO 63122_______________________________________
                         Phone: 314-965-8410                                         Fax: 314-965-8756
                         Email: _______________________________________________________________
                         NPI #: 1043296494______________________________________________

                         Primary ICD-9 Code: 278.01 Secondary ICD-9 Code (if applicable) ______________
                         CPT Code 1: 43770               CPT Code 2: _________________________________
     Procedure               * Benefits cannot be verified without a Diagnosis CPT code.
    Information                Surgery Date (if scheduled): ___________________________________
                               Site of Service: Ambulatory Surgical Center (ASC)  Hospital outpatient
                                                Hospital Inpatient

                         Asthma                                                 Obstructive Sleep Apnea
                         Depression                                             Osteoarthritis
    Comorbid             GERD/Heartburn                                         Pseudotumor Cerebri
    Conditions           Hypercholesterolemia                                   Swelling of the Legs (edema)
                         Hyperlipidemia                                         Type 2 Diabetes
                         Hypertension/High Blood Pressure                       Urinary Stress Incontinence

                         Name of Insurance Company: ______________________________________________
                         Address: _______________________________________________________________
                         City, State, Zip: _________________________________________________________
      Primary            Phone: ________________________________ Fax: __________________________
                         Policyholder’s Name: ____________________ Relationship to patient: ___________
     Insurance           Date of Birth: __________________________              Policy ID #: ____________________
    Information          Group Plan #: __________________________
                         Employers Name: _______________________________________________________
                         Surgeon’s Provider # (required for Medicare or Medicaid) _____________________________
                         Surgeon’s participation with the insurer?: Participating Non-Participating
                         Name of Insurance Company: ______________________________________________
                         Address: _______________________________________________________________
                         City, State, Zip: _________________________________________________________
     Secondary           Phone: ________________________________ Fax: __________________________
                         Policyholder’s Name: ____________________ Relationship to patient: ___________
     Insurance           Date of Birth: __________________________              Policy ID #: ____________________
    Information          Group Plan #: __________________________
                         Employers Name: _______________________________________________________
                         Surgeon’s Provider # (required for Medicare or Medicaid) _____________________________
                         Surgeon’s participation with the insurer?: Participating Non-Participating