Sinai Hospital of Baltimore. Division of Bariatric Surgery. Hoffberger Building, Suite # West Belvedere Avenue Baltimore, MD 21215

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1 Dear Patient: Thank you for inquiring about our weight loss surgery program! The decision to undergo weight loss surgery is not a decision you made quickly; in a similar fashion, the process of preparing you for surgery also cannot occur quickly, nor be rushed. Please take the time to fill out the enclosed intake form carefully and completely. Return it to the address listed above. Remember to attach a legible copy of your picture ID along with your medical insurance card (front & back). Our staff will then contact you to give you an appointment date, usually within two weeks of receipt of your application. In the meantime, we encourage you to attend our monthly informational seminars, which we hold at Sinai Hospital s Zamoiski Auditorium. We will be present at each seminar, as well as, members from our staff and post-op patients. Everyone is invited to attend, but be sure to verify the dates on our website ( or call (410) We understand that this waiting period between sending the application form and your initial appointment is frustrating, but you can still be productive during this period. As we begin the insurance pre-certification process, your plan will likely require extensive documentation to ensure that they will approve the surgery. If you prefer, you can obtain some of this documentation BEFORE your initial consultation. If you can obtain the documents, it will allow us to schedule your surgery more quickly. The following are required by ALL insurance companies of all patients prior to scheduling surgery: 1) Proof of attendance at a minimum of one of our bariatric seminars. 2) Nutritional consultation: There is a mandatory $ program fee (not covered by any insurance) due at the initial appointment. This covers the mandatory pre- and post-surgical nutrition classes, presented by the Bariatric surgery program s dietitian, as well as, unlimited dietary consultations for 1 year. 3) A letter from your primary care physician. This letter should summarize your diet history, your obesityrelated medical problems and any physician-supervised weight loss attempts that you have had. It should also include a sentence or two stating that your physician feels that you are a good candidate to undergo surgery. 4) Psychology/psychiatry clearance: all patients are required to undergo a psychological evaluation prior to surgery, so that we can document adequate knowledge of the procedure, reasonable weight loss expectations, and the ability to comply with the rigorous dietary restrictions post-operatively. You can obtain clearance from your own psychologist or psychiatrist if you prefer. Every patient will require additional pre-operative testing, but these tests will be ordered on an individual basis after you have met with one of the surgeons. Also, some insurance companies (Blue Cross/ Blue Shield from MD, MAMSI, Aetna, Cigna, and Medicare) are requiring that policy holders be seen monthly for 3-6 consecutive months to document weight loss attempts and progress. Once all of the above requirements, including any additional pre-operative tests, are met we will be able to select a date for surgery. If you have any questions about the Bariatric Surgery Program at Sinai Hospital, please contact us at and one of our staff will be glad to help you. We look forward to meeting you in the near future. Christina Li, MD, FACS and Cynthia Long, MD, FACS ****KEEP THIS PAGE*** 1

2 AVOID these medications 2 weeks prior to surgery and call the office before taking any new medication for pain management Aspirin Products: Acuprin Aggrenox Alka-Seltzer Anacin Bayer BC Bufferin Butalbital Carisoprodol Darvon Disalcid Doan s Dristan Easprin Ecotrin Endodan Equagesic Excedrin Fiorinal Gelprin Goody s Halfprin Helidac Aspirin Products: Kaopectate Lobac Lortab Magan Magsal Methocarbamol Mono-gesic Norgesic Norwich Aspirin Pamprin Pepto-Bismol Percodan Propoxyphene Robaxisal Salflex Salsalate Sine-Off Soma St. Joseph s Aspirin Synalgos-DC Talwin Trilisate Vanquish YSP Aspirin NSAIDS products: Acular Advil Aleve Anaprox Bextra Cataflam Celebrex Clinoril Daypro Feldene Indocin Lodine Mobic Motrin Naprosyn Naprelan Orudis Relafen Toradol Voltaren ****KEEP THIS PAGE*** 2

3 Application Process 1. Call your insurance company and complete the Insurance Verification form on page Complete the Patient Application on pages 5-12 and the Nutritional Assessment on pages Return the Insurance Verification, Patient Application, and the Nutritional Assessment to our office (pages 4 18). a. Please keep the folder & resource papers in the right sleeve. 4. Our office staff will verify your insurance benefits. 5. One of the physicians will review your application. 6. Our office staff will call you to schedule an initial appointment with the physician and dietitian. a. Reminder: the nutritional consultation has a mandatory $ program fee (not covered by any insurance) which is due at the initial appointment. b. All self-pay portions are due at the time of service. c. We accept only cash or credit cards as payment. We do not accept checks. 7. Please allow 1-2 weeks, plus mailing time for our staff to contact you. 8. While waiting to hear from our office you can complete the following steps: a. Contact your Primary Care Physician for any necessary referrals per your insurance requirement. (Some offices require 1-2 weeks notice to have referrals ready). b. Attend one of our bariatric seminars (see enclosed flyer for dates). Please include copy of driver s license and insurance card (front & back) with application 3

4 Insurance Verification Form Call to verify insurance coverage for bariatric surgery. The telephone number is located on the back of your insurance card. This completed form must be submitted with your application. First Name: Last Name: Insurance Company: Insurance Phone No.: Date Insurance Company Called: Middle Initial: Birth Date: Spoke with: Type of Plan: HMO POS PPO MCO Medicare Other: Policy No.: Group No.: Effective Date: Ask your insurance representative the following questions: 1. Is this a small group policy? Yes No 2. Does this policy have ANY exclusion for Bariatric Surgery or Morbid Obesity? Yes No 3. Does the insurance cover the following procedures: a. Gastric Bypass (CPT 43644) Yes No b. Gastric Banding (CPT 43770) Yes No c. Sleeve Gastrectomy (CPT 43775) Yes No 4. Is this procedure subject to any pre-existing conditions on the policy? If yes, Yes No please list 5. Are there specific criteria that need to be met in order to qualify for this Yes No surgery? If yes, please list: months a. Total months of consecutive supervised weight loss b. Other: 5. Do you need a referral from your Primary Care Physician to see the bariatric surgeon? Yes No 6. Is there a co-pay to see the bariatric surgeon? a. What is the co-pay? 7. Do you have a deductible? a. What is the amount? b. How much of the deductible has been met? Yes No $ Yes No $ $ Please include a copy of your driver s license and insurance card (front & back) with the application 4

5 Patient Application NAME: Date: I am interested in having: -CHOOSE A PROCEDURE - Gastric Bypass Laparoscopic Band Sleeve Gastrectomy First Name: Middle Initial: Last Name: Gender: M F Social Security No.: Birth Date: Current Age: Weight: Height: BMI: (If known) Mother s Maiden Name: Contact Information: Home Address: Apt/Unit #: City: State: Zip: May we contact you at this number? Home Number: Yes No Preferred Cell Number: Yes No Preferred Work Number: Yes No Preferred Employed: Yes No Full Time Part Time Retired Disabled Employer: Occupation: Employers Address: Length of current employment: Years Months 5

6 NAME: Emergency Contact Information: Sinai Hospital of Baltimore Name: Home Address: Home Number: Relationship: City, State, Zip: Cell Number: Work Number: Pharmacy Information: Pharmacy Name: Address: Phone Number: City, State, Zip: Fax Number: Physician Information: Primary Care Physician Other Physician Name: Specialty: Address: Address 2: City: State: Zip: Phone Number: Fax Number: 6

7 NAME: Insurance Information: Insurance Carrier Name: Group Number: ID Number: Policyholder s Name: Policyholder s DOB: Policyholder s SS#: Relationship to Insured: Insurance Address: City, State, Zip: Phone Number: Fax Number: Primary Insurance Secondary Insurance I heard about Sinai Bariatric through: Family/Friend Magazine Insurance Newspaper Internet Primary Care Physician TV Other: 7

8 NAME: The doctor will complete this section. CC: Morbid obesity HP: This is a year old male/female P G A morbid obese patient interested in bariatric surgery. Current weight is lbs. with a BMI of. Patient s ideal weight should be lbs. for a BMI of. Excess weight has been calculated as lbs. Patient has been unable to control or reduce their weight by medical management. Past Medical History (all that apply): Anxiety Fibromyalgia Reflux Disease (Heartburn or severe indigestion) Heart Attack Seizures Asthma High blood pressure Sleep Apnea (Hypertension) Diagnosed Observed Bronchitis Hypercholesterolemia (High cholesterol) Snore Cancer Hypertriglyceridemia (High triglycerides) Stress Incontinence Cardiac Surgery Hyperthyroidism Stroke Chest Pains Hypothyroidism Varicose Veins CHF Leg Ulcers Other : Depression Diabetes Type I (Insulin dependent) Diabetes Type II (Non-insulin dependent) DVT (Leg Blood Clots) Lower back pain Migraines/Headache Peripheral Edema (Swelling of the legs) Pneumonia 8

9 NAME: Surgical History (all that apply): Surgery Date Comment Check if no surgical history C section Number: Gall Bladder Open Laparoscopic Hernia Hiatal Inguinal Incisional Umbilical Hysterectomy Abdominal Vaginal Obesity previous Band Gastric By-pass Sleeve Orthopedic Type: Tubal Ligation Other (list surgeries and year) : Hospital Admissions: Check never been admitted to the hospital Hospital Date Reason 9

10 NAME: Health History (all that apply): HEAD AND NECK CARDIOVASCULAR RESPIRATORY GASTROINTESTINAL URINARY Change in vision Ringing in ears Nosebleeds Double vision Dizziness Hoarseness Deafness Sinusitis Other Palpitation Leg pain w/ walking High cholesterol Chest Pain Shortness of breath Heart disease History of heart attack Other (please list): Cough Asthma/Bronchitis Shortness of Breath Wheezing Sleep Apnea Diagnosed Observed Other (please list): Loss of appetite Abdominal pain Changes in bowel habits Difficulty w/ swallowing Vomiting History of blood transfusion Nausea Bloody Stools History of polyps Belching/ Excess Gas Difficulty urinating Urinating at night Jaundice Stress incontinence Kidney stones Other (please list) Other (please list) Back pain Itching Seizures ORTHOPEDICS Change in hair Difficulty walking History of fractures Weakness Other (please list) Body Aches Numbness or tingling PSYCHIATRIC ENDOCRINE HEMATOLOGY ALLERGIES Panic attacks Sleeping difficulties Bipolar disorder Chronic depression Thyroid Problems Menstrual Problem Anemia Bleeding Attempted suicide Hair Loss Diabetes Insulin Non-Insulin Enlarged lymph nodes History of cancer Other (please list) Other (please list) Other (please list) Eczema Hay fever Asthma 10

11 NAME: Drug Allergies: Medication Allergies Check if no allergies Type of reaction Current medication (prescription and non-prescription): Medication Strength Frequency Purpose Check if no medications Started (Initials /Date) Stopped (Initials /Date) 11

12 Social History: Sinai Hospital of Baltimore NAME: Marital Status: Single Married Divorced Separated Widowed Ethnic Origin: Black/African American Hispanic White/Caucasian Asian/Oriental Other: Religion: Catholic Jehovah Witness Jewish Prostestant Other (List): Education: 9 to 11 years High School Graduate/GED Vocational/Technical Some College College Graduate Post Graduate Degree Do you use tobacco products? If yes, what kind: Cigarettes Cigars Chewing tobacco Number of Children: None or more Yes No If yes, how much: 1/2 pack or less per day Between packs per day Between packs per day 2 packs or more per day Do you drink alcohol? Yes If yes, how much: Less than 2 per day Between 2 5 per day Between 6 10 per day More than 11 per day No If yes, how often: Daily Weekly Monthly Occasionally Have you ever uses illegal drugs? Yes No If yes, what kind: Marijuana Cocaine Heroin Amphetamines If you still use drugs, how often: Daily Weekly Monthly Occasionally List the diets/programs have you have tried within the last 5 years: Diet or Weight Loss Medication Year Length in Months Number of Pounds Lost Check if you have used the following medications to lose weight: Orlistat (Xenical) Meridia Phentermine Phen-Fen B-12 shots Other Check the eating behaviors which have contributed to weight gain: Skipped meals Frequent sweets Vomiting after large meals Large portions High carbohydrate diet Frequent snacking Fatty foods Binge eating Fast foods Emotional eating Laxative use Other: 12

13 Family History: NAME: Mother Weight Diabetes Heart Disease High BP High Cholesterol Health Problems Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Father Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Maternal Grandmother (Mother s Mother) Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Maternal Grandfather (Mother s Father) Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Fraternal Grandmother (Father s Mother) Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Fraternal Grandfather (Father s Father) Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Sibling Brother Sister Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Sibling Brother Sister Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Sibling Brother Sister Diabetes Heart Disease High BP High Cholesterol Sleep Apnea Joint Disease Stroke COPD Obesity Reflux Disease Lupus Other: Sibling Brother Sister Diabetes Sleep Apnea Obesity Heart Disease Joint Disease Reflux Disease High BP 6 (office) Stroke (fax) Lupus Web Site: Lifebridgehealth.org/bariatricsurgery High Cholesterol COPD bariatric@lifebridgehealth.o Other: rg 13

14 Additional Information HMO S, POINT OF SERVICE, AND MANAGED CARE PLANS: If your insurance company is an HMO, point of service, or managed care plan, you must obtain a written out-of-network referral before your consult with the surgeon. You must follow the rules of your insurance company in order to obtain the highest level of benefits. Your primary care physician s office will need to contact the insurance company for a referral. You may make an appointment with the surgeon; however, the referral must be received or brought with you to the appointment. SELF PAY PATIENTS: If your insurance does not cover gastric bypass surgery and you wish to proceed as a cash patient, please contact the office for fees and scheduling information. PROGRAM FEE: A $150 program fee is required at your initial appointment. This fee is nonrefundable and covers 1 year of unlimited visits or consultations with the nutritionist. PAIN MEDICINE: Do not take any pain medication/anti-inflammatories three weeks prior to surgery without consulting with your surgeon (see list on page 2). Most pain medicines increase the chance of bleeding. This may result in cancellation of your procedure. Effective 3/1/2009 We only accept cash or credit card as acceptable form of payment. Effective 11/15/2009 We require 24 hour notice if you are unable to keep your scheduled appointment. A fee of $25 will be billed to you for each missed appointment. 14

15 NAME: Sinai Hospital of Baltimore Nutrition & Eating Habits Questionnaire Complete the following questions. Please fill out as honestly and as with much detail as possible. Turn this in with your application. Please list any food or drink you have consumed in the past 24 hours: Meal Time Place What & how much Breakfast Snack Lunch Snack Dinner Snack 1. Do you have any food allergies? Yes No If yes, which foods and type of allergic reaction? 2. Do you have any food intolerance s? Yes No If yes, please circle which food causes intolerance? Lactose Spicy Acidic Caffeine MSG Sugar substitutes Other: 3. What do you do for a living and how many hours do you work per week? 4. Do you travel with your career? Yes No If yes, how often? 5. Marital status: Single Married Divorce Number of children 6. Who prepares the meals in your home? 7. Who does the grocery shopping? 15

16 NAME: 8. Are there any religious, ethnic, or cultural factors affecting food choices? Yes No If yes, please elaborate 9. How are meals prepared at home? Fried Baked Sautéed Other 10. What kind of fats do you use for cooking at home? Butter Margarine Olive Oil PAM type spray Shortening or Lard Other: 11. What kind of spreads do you use for bread? Reduced calorie margarine Margarine Butter Other: 12. Do you use sugar substitutes? Yes No If yes, which one? 13. What kinds of beverages do you drink and how much how often? How often per day/week How much (ounces) Regular Coffee/Tea Decaf coffee/tea Regular Soda Diet Soda Juice Other drinks with sugar 14. What is the food/drink that you will have the hardest time giving up? 15. Describe frequent cravings: 16. Do you wake up in the middle of the night hungry? Yes No If yes, how often? Do you remember what you eat? Always Sometimes Never 17. How many days per week do you eat breakfast? How many hours after you wake up do you eat your first meal? 18. How many meals do you eat away from home on weekdays? Breakfast Lunch Dinner 19. How many meals do you eat away from home on the weekends? Breakfast Lunch Dinner 16

17 NAME: 20. List the restaurants where you often eat: 21. Do you eat when you are? Bored Happy Sad Stressed 22. Do you ever binge on food until you are uncomfortable or ill? Yes No If yes, how often? 23. Do you drink alcohol? Yes No If yes, how many at a time and how often? 24. Do you smoke? Yes No If yes, how many cigarettes a day? 25. Do you exercise now? Yes No If yes, what exercise do you do and how often do you exercise? 26. Is there any reason why you cannot exercise or should not exercise? 27. Has your weight changed in the past year? Yes No If so, how much have you gained or lost? Gained pounds Lost pounds 28. What do you think is a realistic weight for you? 29. List the diets/programs have you have tried within the last 5 years: Diet or Weight Loss Medication Year Length in Months Number of Pounds Lost 30. Have you had a previous weight loss surgery? Yes No If yes, list the date the surgery was performed, which procedure was done, and where the procedure was performed. 17

18 NAME: 31. What kind of education were you given with the previous weight loss surgery? 32. Do you currently take vitamins or minerals? Yes No If yes, list the names and amounts you take: 33. Do you use any meal replacement products (liquids, bars, protein shakes)? Yes No If yes, which ones and how often? 34. Do you use any other dietary supplements on a regular basis? Yes No Black Kohash DHEA Fiber powders/tablets Fish or Flaxseed oil Garlic pills Glucosamine Chondrontin Herbs Premarin Amounts: 35. Have you had any history with eating disorders (Binge eating and then vomiting or not eating or eating very little for long periods of time)? Yes No If so, please be specific on age/type of eating disorder/year disorder occurred/ duration of disorder and circumstances that were contributing to the issue. If you were professionally treated, how long ago was the treatment and did you receive clearance from your doctor? 36. Do you have any special needs for education material due to: Reading problems Deafness Poor eyesight Other: Melissa Majumdar, RD, LDN (office) mmajumda@lifebridgehealth.org Form developed by Nancy Lum RD LD 18