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Letter of Referral for Weight Loss Surgery
Patient Name: _______________________________________ DOB: ___________________
The patient named above is a patient of mine with a longstanding history of obesity that has been refrac-tory to medical weight loss regimens. The patient’s obesity related comorbidities include:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The patient’s additional medical history is significant for:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The patient’s most recently recorded height and weight: Height: ___________ Weight: ___________ BMI: __________ Date: _______________
My patient is motivated to make lifestyle changes required to maximize the likelihood of successful, sustained weight loss and would therefore benefit from consideration for weight loss surgery in order to improve their overall health, quality of life, and to minimize their risk of obesity related comorbidities. Please evaluate my patient as a candidate for weight loss surgery.
If considered an appropriate candidate:
The patient is medically cleared for surgery
I will need to see the patient back again in the office for formal pre-operative clearance
Physicians Signature: _______________________________________ Date: ______________
I have also enclosed documentation of prior weight loss efforts and the patient’s weights at our office.
Updated 11.11.10
Patient Demographics
Name: _________________________________Address: _______________________________ ________________________________ ________________________________ City State Zip County
Marital Status: ____________________________Spouse’s Name: __________________________
DOB: ______________Age:_______ Sex: M FHome Phone: ____________________________ Work Phone: _____________________________Cell Phone: ______________________________Email: __________________________________ Social Security #: _________________________May we contact your spouse? Y N
Emergency Contacts: ________________________________________________________________________ Name Relationship Phone Alternate Phone
________________________________________________________________________ Name Relationship Phone Alternate Phone
Are you employed? Y NFull Time Part Time Student Homemaker Retired Self Employed
Medical History
Insurance InformationEmployer Name: __________________________
Address: ________________________________ ________________________________ ________________________________ ________________________________ City State Zip County
Policy Holder Name: _______________________
Occupation: _____________________________
Policy Effective Date: ______________________Customer Service #:_______________________Policy or ID #: ____________________________ ________________________________
Relationship to Patient:_____________________
Primary Insurance Carrier: _____________________________________________________________
Address: ________________________________ ________________________________ ________________________________ ________________________________ City State Zip County
Policy Holder Name: _______________________
Policy Effective Date: ______________________Customer Service #:_______________________Policy or ID #: ____________________________ ________________________________
Relationship to Patient:_____________________
Secondary Insurance Carrier: _____________________________________________________________
1Updated 06.28.10
Who is your current employer? __________________________________________________________
2
Weight History
Current Weight ____________ Max Weight _____________ Lowest Adult Weight ____________Height: __________________ Date of Max Wt: __________ Date of Lowest Weight: __________BMI: ____________________
How would you describe your current weight? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________
At what weight have you felt your best or think you would feel your best? ______________________________
How does your weight affect your daily activities? ________________________________________________________________________________________________________________________________________
Why do you want to lose weight? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Why are you considering surgery to help you lose weight? _________________________________________________________________________________________________________________________________________________________________________________________________________________________
How do you think your life would change if you reach your weight goal? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Age when you first began dieting? ____________Age when you first remember being overweight? _________
Medications Prescribed by a Phsyician for Weight LossMedications may be listed as both generic and name brand. Check the one prescribed to you.
AcutrimAdipiex-PAnorexDexatrimDexfenfluramineDidrexFastinFenfluramineIonaminMazanorMeridia
Stacker 2CoritslimEphedrineRelacoreOther _______________________ _______________________ _______________________
ObalanOrlistatPhenterminePhentrolPondiminReduxSanorexTepanolTopamaxTenuateXenical
3
Weight Loss History
Most insurance companies require documented evidence of previous weight loss attempts, so it is very important that you complete this in detail.
Method Ages# of Times
TiredWeight
LostComments/Weight Regain
Weight WatchersTOPSFirst PlaceNutri-SystemJenny CraigLA Weight LossRichard SimmonsOvereaters AnonymousHerbal LifeDietitianSlim FastLiquid DietCabbage Soup DietMayo Clinic DietScarsdale DietAtkinsSouth Beach DietSugar BusterHigh Carbohydrate, Low FatStarvationBehavior ModificationPsychotherapyHypnosisSurgeryDiet BooksCalorie CountingDr. VitkinsDr. JagiellaDr. MartinExerciseOther (Please Describe)
Please enclose any documentation confirming your weight loss efforts.
Medical History
Have you ever had any of the following medical problems? (Choose one in each box that applies)
Hypertension (High Blood Pressure)
No personal historyBorderline, no medicationDiagnosis of hypertension, no medicationTreatment with single medicationTreatment with multiple medicationsPoorly controlled by medication, organ damage
Congestive Heart Failure No personal history or symptoms of congestive heart failureSymptoms with more than one ordinary activitySymptoms with ordinary activitySymptoms with minimal activitySymptoms at rest
Ischemic Heart Disease
Chest Pain
Peripheral Vascular Disease
No history of ischemic heart diseaseAbnormal ECG, no active ischemiaHistory of heart attack or take medications to prevent itHad surgeries or stents for heart attackActive ischemia
No symptoms of peripheral vascular diseaseCramping pain and weakness in the legs with medicationTransient ischemic attack (ie TIA or mini-stroke)Procedure for peripheral vascular diseaseStroke, loss of tissue secondary to ischemia
No chest pain symptoms/anginaChest pain with extreme exertion (running, swimming, etc.)Chest pain occurs with moderate activity or exertionChest pain occurs with minimal exertion (walking across room) or “at rest”Unstable chest pain/agina
(Coronary Artery Disease, Ischemic means that the heart is not getting enough blood and oxygen)
(A disease of the blood vessels characterized by narrowing and hardening of the arteries)
Lower Extremity Edema (swelling)
No symptoms of lower extremity edemaIntermittent lower extremity edema, not requiring treatmentSymptoms requiring treatment, diuretics, elevation or hoseStasis ulcersDisability, decreased function, hospitalization
DVT/PE (Deep Vein Thrombosis/Pulmanary Embolism)
No history of DVT/PEHistory of DVT resolved with medicationRecurrent DVT long term medicationPrevious pulmonary embolismRecurrnent pulmonary embolism, decrease function, hospitalizationVena Cava filter placed
4
5
Glucose Metabolism No symptoms or evidence of diabetesElevated fasting glucoseDiabetes, controlled with oral medicationDiabetes, controlled with insulinDiabetes, controlled with insulin and oral medicationDiabetes, with severe complications (blindness, retinopathy)
Abnormal Lipids (such as high cholesterol, high bad cholesterol)
Not presentPresent, no treatment requiredControlled with lifestyle changeControlled with single medicationsControlled with multiple medicationsNot controlled
Gout/Hyperuricemia
Obstructive Sleep Apnea Syndrome
Obesity Hypoventilation Syndrome
No symptoms of gout/hyperuricemiaHyperuricemia, no symtomsHyperuricemia, medicationsJoint disease due to goutDestructive jointsDisability , unable to walk
No symptoms of obesity SOB (shortness of breath)Lack of oxygen on room airSevere SOBPulmonary HypertensionRight Heart Failure
No symptoms or evidence of sleep apneaSleep apnea symptoms (negative sleep study or not done)Sleep apnea diagnosis by sleep study (no oral appliance)Sleep apnea requiring oral appliance such as CPAPSleep Apnea with significant hypoxia or oxygen dependentSleep apnea with complications (pulmonary hypertension)
(excess uric acid in the blood)
Pulmonary Hypertension No symptoms or indication of pulmonary hypertensionSymptoms associated with PH (tiredness, OSB, dizziness, fainting)Confirmed Pulmonary Hypertension diagnosisWell controlled on anticoagulants and/or calcium channel blockerStronger medications and/or oxygen
Asthma No symptoms of asthmaIntermittent mild symptoms, no medicationSymptoms controlled with oral inhaler (such as albuterol)Well controlled with ongoing daily medicationSymptoms not well controlled with medicationHospitalized within last 2 years or history of intubation
6
GERD No history of GERDIntermittent or variable symptoms, no medicaitonIntermittent medicationTake prescribed medication (H2 blocker or low dose PPI)Take high dose medicationMeet criteria for antireflux surgery, or prior surgery for GERD)
Liver Disease No history of liver diseaseMild enlargement of the liver, normal liver function test, fatty changeModest hepatomegaly, LFT alteration, fatty changeModerate to marked hepatomegaly, fatty changeMild inflammation, mild fibrosisDefinite NASH (nonalcoholic steatohepatits), cirrhosis, hepatic dysfunction by LFT’sHepatic failure, transplant indicated or done
Back Pain
Musculoskeletal Disease
Fibromyalgia
Polycystic Ovarian Syndrome(PCOS)
No symptoms of back painIntermittent symptoms not requiring treatmentSymptoms requiring non narcotic treatmentDegenerative changes or positive objective findings, symptoms requiring narcotic treatmentSurgical intervention done or recommended pending weight lossFailed previous surgical intervention with existing symptomsNo symptoms of musculoskeletal diseasePain with community ambulationNon narcotic pain medication requiredPain with household ambulation Surgical intervention requiredAwaiting or past joint replacement or other disability
(problems with muscle and bone such as joint disease)
No history of fibromyalgiaTreatment with exerciseTreatment with non narcotic medicationTreatment with narcoticsTreatment with narcotics; surgical intervention done or recommendedDisabling, treatment not effectiveNo history of polycystic ovarian syndromeSymptoms of PCOS, no treatmentTake birth control pillsTake Metformin (Glucophage) or TZD (thiazolidinedione)Combination therapyInfertility
(chronic disorder with widespread pain, tenderness, and stiffness of muscles)
7
Psychosocial Impairment
Depression
Confirmed Mental Health Diagnosis
Stress Urinary Incontinence
Pseudotumor Cerebri
No impairmentMild impairment in psychosocial functioning but able to perform all primary tasksModerate impairment in psychosocial functioning and unable to perform some primary tasksSevere impairment in psychosocial functioning and unable to perform most primary tasksSevere impairment in psychosocial functioning and unable to functionNo symptoms of depressionMild and episodic not requiring treatmentModerate accompanied by some impairment, may require treatmentModerate with significant impairment, treatment indicatedSevere, definitely requiring intensive treatmentSevere requiring hospitalizationNoneBipolar DisorderAnxiety/Panic DisorderPersonality DisorderPsychosis
(leaky urine when you laugh, cough, or sneeze)
No history of stress urinary incontinenceMinimal and intermittentFrequent but not severeDaily occurence, requires sanitary padDisablingOperation ineffective
(benign intracranial hypertension. An abnormal condition such as headaches with dizziness, nausea, and/or pain behind the eyes)
No symptoms of pseudotumor cerebriHeadaches with dizziness, nausea, and/or pain behind the eyes, no visual symptomsHeadaches with visual symptoms and/or controlled with diureticsPatient has had MRI to confirm PTC, is well controlled with oral diureticsPatient is well controlled with stronger medicationsPatient requires narcotics or has had (or needs) surgical intervention
List all additional medical illness:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List all surgeries you have had:
Surgery Date Open or Laparoscopic
List allergies to any medication and include type of reaction and date of allergy:Penicillin IodineLatex
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medications:
Medication Dose & Frequency Condition
example: Prilosec OTC 30mg once a day Heartburn
Please enclose an additional sheet if necessary to list ALL medications
8
Do you CURRENTLY have a problem with any of the following?
Social HistoryDo you use tobacco currently? __________How many years have you smoked? _____
Sleep History
9
FeverNight SweatsLethargyLoss of AppetiteDizzinessHeadacheChange in visionHearingSinusesNose BleedsChronic CoughShortness of breathWheezing
PregnancyLast period: __________BreastTrouble walkingWeakness in arms/legsNumbness/tinglingJoint painSwellingInfectionAnxietySadnessFear
SnoringPalpitationsBleedingNauseaVomittingDifficulty swallowingBloatingDiarrheaConstipationBloody StoolChange in stoolUrinationKidneys
Did you smoke in the past? ____________How many years did you smoke? _______
Do you use any recreational drugs? __________________ Which ones? _______________________Have you ever had an addiction to drugs? _____________ _______________________
How many pack/day? _________________Have you tried to quit? ________________
How many pack/day? _________________Have you tried to quit? ________________
How likely are you to doze off or fall asleep in the following situations? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Please fill out the box below.
0= would never doze 2= moderate change of dozing1= slight change of dozing 3= high chance of dozing
0 1 2 3Sitting and Reading
Watching TV
Sitting, inactive in a public place (a theater or in a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic (at a traffic light)
Family History
10
Mother Father Sibling Aunt/Uncle Grandparent
Obesity
Diabetes
Heart Disease
High Blood Pressure
High Cholesterol
Cancer
Arthritis
Early Death (Cause)
Physicians
Please list all physicians that are currently or recently caring for you:
Primary Care __________________________________________________________________________Physician __________________________________________________________________________ __________________________________________________________________________
Gynecologist __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
Pulmonologist __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
Psychiatrist/ __________________________________________________________________________Psychologist __________________________________________________________________________ __________________________________________________________________________
Orthopedic __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
Other __________________________________________________________________________ __________________________________________________________________________
Referring Physician
11
Referring Physician: _____________________________ Phone Number: _____________________Address: ______________________________________ Fax Number: _______________________ ______________________________________ ______________________________________
How did you hear about the Floyd Center for Bariatric Services? __________________________________________________________________________________________________________________________________________________________________
Procedure Preference
Which surgical procedure are you currently most interested in?
Gastric Bypass Realize BandLap-Band Sleeve Gastrectomy No Preference
Authorization to Share Health Information
I, ____________________________, allow my doctor(s), my health plan or insurers, and any other healthcare providers to give medical information relating to my use or need for weight loss surgery to P-Verify, Inc.
P-Verify, Inc. runs the Bariatric & Metabolic Intelligence (BMI) Reimbursement Support Program. This information can include spoken or written facts about my health or payment benefits I may have. It can include copies of records from my healthcare providers or health plans about my health or care.
P-Verify, inc. will use and give out this information to check to see if I have coverage for weight loss surgery. I know that people who work for and with P-Verify, Inc. may use and see my information, but they may use it only as allowed in this form.
This Authorization will last for 3 years after the date I sign this form. If I change my mind before that time, I can tell my doctor, healthcare provider, and/or my insurer in writing that I do not want them to share any more information with P-Verify, Inc. but it will not change any actions they took before I told them. I know that I have a right to see or copy the information my healthcare providers or insurers have given to P-Verify, Inc.
I KNOW THAT I MAY REFUSE TO SIGN THIS FORM. My choice about whether to sign this form will not change the way my healthcare providers treat me. If I refuse to sign this form, I know that this means I may no longer be able to receive assistance from the BMI Reimbursement Support Program.
I understand that P-Verify, Inc. does not promise to find ways to pay for my weight loss surgery, and I know that I may have to pay the costs of my care.
Patient Signature: _________________________________________ Date __________________________(If the patient is unable to sign, patient’s representative must sign below)
Patient’s Name: ________________________________________
By: __________________________________________________(Signature of person signing for patient)
Describe relationship to patient and right to act for patient:______________________________________________________________________________________
Updated 06.03.10
Medical Information Release Authorization
Patient Name
Birth Date Social Security No.
Address
Home Telephone: ( )
Alternate Telephone: ( )
I hereby authorize _________________________________________________________________________________ Name & Address of Individual/Organization who is being asked to release records to release information from the medical records of the above- named patient to: ________________________________________________________________________________________________ Name and address of person / organization to whom disclosure is to be made Purpose of Disclosure: (A reason must be provided)
At the request of the individual signing this authorization
Other (Specify): ________________________________________________________________________________ For the following treatment dates:
All dates of treatment
For dates of treatment from __________________ to ___________________ Specific description of information to be disclosed:
All records for the time period indicated above
Other (Specify): ________________________________________________
____________________ ____________________________________________ ___________________________ Date Signature of Patient or Person Relationship to Patient Authorized to Act on Patient’s Behalf
.
This authorization expires 90 days from the date specified above or the date on which the requested release of information has been completed, whichever comes first. This release covers records of treatment only for the dates specified above. Fees/Charges will comply with all laws and regulations applicable to release of information.
I understand that any information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that I may revoke this authorization in writing at any time by sending the revocation to the health care provider indicated above, except to the extent that action has already been taken in reliance on this authorization. Aside from this, I understand that upon expiration of the authorization, no further disclosure of the information may be made. I understand that a health care provider may decline to treat me if I refuse to sign this authorization only when the treatment is for the sole purpose of creating health information for disclosure to a third party. I further understand that the records/information to be released may contain or consist of information related to the following: contagious diseases (HIV/AIDS, tuberculosis, hepatits, etc.); psychiatric treatment or psychotherapy; and drug/alcohol abuse treatment.
Updated 06.03.10