Your Body. Your Life. Start Today. Patient Packet

Transcription

1 Your Body. Your Life. Start Today. Patient Packet

2 Thank you for your interest in SSM Health Weight Management Services. Completing this application packet is the first-step in getting started with our surgical and non-surgical program. Once the attached paperwork is completed it can either be ed back to us at or faxed to Your timely completion of all the attached paperwork will expedite the process of getting started with our program. Once the paperwork is completed and returned, your application packet will be processed, insurance verified and you will be contacted within 3-5 business days about your next steps. Weight-Loss Surgery Applicants PLEASE READ: If you re interested in weight-loss surgery it is strongly recommended that you call your insurance and inquire about your benefits, the requirements to meet medicalnecessity, and pre-authorization for surgical treatment of morbid obesity. When inquiring about weight-loss surgery with your insurance company they may ask for a procedure code, commonly referred to as a CPT code. The CPT code for the Roux-en-Y Gastric Bypass is 43644, the Sleeve Gastrectomy is 43775, the Duodenal Switch is 43845, and the Adjustable Gastric Band is Please note that NOT all insurance policies cover weight-loss surgery. If you need help or have additional questions about our application packet, please call DPS (3/2018)

3 Thank you for making SSM Health Weight Management Services your provider of choice. We know insurance plan deductibles and co-pays vary and can be complicated. In an effort to make this easier for you, once you are approved and scheduled for surgery, you should expect a Patient Payment Obligation Estimate Letter from the SSM Health customer service team about your upcoming procedure at the hospital to provide you with an estimate of the amount you will be expected to pay for hospital services based on your insurance coverage. This is considered your patient responsibility, or out-of-pocket expense, after your insurance has paid its portion. The estimate will not include non-hospital services such as physician services. Please take this opportunity to learn more about payment options available to you. Your Payment Options: Same-day payment in full You can make a payment prior to your procedure or pay in full on the day of your procedure. Commerce Bank (No Cost/No Interest) Health Services Financing Program To assist in making your medical bills more manageable, SSM Health offers a zero cost, zero interest health services financing program that spreads payments out over time. There is NO credit check, NO origination fees and NO pre-payment penalty. Options Include: 24 Month, 0% Interest Financing for balances of $600 - $4, Month, 0% Interest Financing for balances of $5,000 - $9, Month, 0% Interest Financing for balances of $10,000 - $50,000 Billing you also can elect to receive a bill for the balance due after insurance payment is received. At SSM Health, we are available to help and advise you along the way to make the billing and payment process convenient and easy to understand. Financial counselors are available in each hospital should you wish to speak with someone in person. You also can contact our Customer Service Department, Monday-Friday 8am-5pm, either by phone at (855) or by at billingquestions@ssmhealth.com.

4 PATIENT INFORMATION PATIENT REGISTRATION LAST NAME FIRST NAME & INITIAL ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE DATE OF BIRTH SEX: o M o F AGE: MARITAL STATUS: o Married o Single RACE: PRIMARY PHYSICIAN SPOUSE S NAME SPOUSE S DOB SPOUSE S WORK PHONE EMERGENCY CONTACT PHONE RELATIONSHIP PATIENT SOCIAL SECURITY # SPOUSE S SOCIAL SECURITY # EMPLOYMENT STATUS: o Full Time o Part Time o Retired o Disabled o Unemployed PATIENT EMPLOYER SPOUSE EMPLOYER WHO ARE YOUR BENEFITS THROUGH? (Check one) o Self o Spouse o Parent RESPONSIBLE PARTY LAST NAME FIRST NAME & INITIAL RELATIONSHIP PHONE RESPONSIBLE PARTY SOCIAL SECURITY # DOB RESPONSIBLE PARTY EMPLOYER EMPLOYER ADDRESS EMPLOYER PHONE INSURANCE INFORMATION 1. PRIMARY INSURANCE PROVIDER/CUSTOMER SERVICE #: POLICYHOLDER LAST NAME FIRST NAME RELATIONSHIP MEMBER ID GROUP NO. 2. SECONDARY INSURANCE PROVIDER/CUSTOMER SERVICE #: POLICYHOLDER LAST NAME FIRST NAME RELATIONSHIP MEMBER ID GROUP NO. I request payment of authorized Medicare, Medigap or any other insurance benefits be made on my behalf to SSM Health Weight Management Services for any services furnished to me by that provider. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents or to other insurers any information needed to determine benefits payable for services from the provider. I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims. FINANCIAL LIABILITY: I understand I am fully responsible for all Physician charges. If I have insurance that will cover a portion of my bill, I agree to pay the patient s portion of the bill and understand I may be required to make a deposit toward the amount and the balance. The fact I may be covered by insurance does not relieve my personal obligations to pay all charges. I agree to assure payment of all charges by SSM Health Weight Management Services. All of the above information I have given is to the best of my knowledge correct. SIGNATURE DATE

5 PATIENT MEDICAL QUESTIONNAIRE Please complete this questionnaire in its entirety. Please be sure to mark your preferred weight-loss option at the top of the page and include all medications. Last Name First Name Date of Birth Gender Height Weight WHICH WEIGHT LOSS OPTION ARE YOU INTERESTED IN? Surgical Medically-Managed Weight Loss (Non-Surgical) Endoscopic Procedures o Roux-en-Y Divided Gastric Bypass o Weight Loss Medications o Balloon (cash only, o Sleeve Gastrectomy o Low-Calorie Diets insurance does not cover) o Duodenal Switch o Adjustable Gastric Band o Revision or modification of previous stomach or intestinal surgery (please obtain medical records from previous surgeon) o Establish Care How did you hear about the SSM Health Weight Management Services? Physician requested: o Dr. Mario Morales o Non-surgical CURRENT MEDICATIONS INCLUDING VITAMINS, OVER-THE-COUNTER MEDICATION, AND INTERMITTENTLY USED DRUGS. (Please list prescription medication first) Name Strength Frequency Purpose When Started PAST MEDICAL HISTORY WHAT MEDICAL PROBLEMS ARE CURRENTLY BEING TREATED? Illness Date Treatment Outcome

6 PATIENT MEDICAL QUESTIONNAIRE PAST SURGICAL HISTORY LIST ANY SURGERIES: Surgery Date Reason Physician FAMILY HISTORY Arthritis-rheumatoid Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Other Asthma Cancer Coronary Artery Disease Diabetes Deep vein thrombosis (DVT/PE) Heart Failure Hypercholesterolemia Hypertension Migraine Osteoarthritis Rashes/Skin Problems Seizures Stroke Thyroid Disease ALLERGIES LIST ALL DRUG ALLERGIES: Drug Name Reaction

7 MENTAL HEALTH BACKGROUND INFORMATION The following information is considered confidential and will be handled as such. Patient Name DOB Are you seeking: o Banding o Bypass o Sleeve o Revision o Non-surgical Do you binge eat or consider yourself to be a compulsive eater? Are you a grazer (consistent snacker or picker)? Do you eat to compensate for stress boredom emotional comfort? If yes to any of these, how do you plan on controlling these behaviors following weight loss surgery? Have you ever had a suicide plan or attempt? o Yes o No If so, when? List any current mental health diagnoses, such as depression, anxiety, etc. and any related medications: How much alcohol do you drink and what type (beer, etc.) List any prior addictions Ever been hospitalized for a psychiatric disorder? How long have you been thinking about having a weight loss procedure? Ways you have researched the surgery Briefly list the surgical risks of the procedure you are seeking Have you ever felt your eating was out of control? Do you ever go on eating binges in which you cannot control the amounts you are eating? Do you ever eat in secret? Have you ever done anything to compensate for overeating such as using a laxative, purging, or skipping meals? Please complete the following question if you are interested in the gastric balloon. Have you ever developed serotonin syndrome? o Yes o No Counseling services are included as part of our program. However, if you already have a counseling provider, you may obtain a weight-loss surgery evaluation with your own provider. The weight-loss surgery evaluation must be a typed report that indicates if you are cleared for bariatric surgery at this time and that evaluates you with respect to: a. Adverse psychiatric conditions: psychosis, severe neurosis, or severe behavioral disorder, which might contraindicate surgery. b. Unreasonable expectations or unrealistic goals. c. Understanding of the risks and discomforts of surgery. d. Ability to understand and comply with instructions and recommendations. e. Acceptance of the need for active participation in the therapy process for life.

8 NON-SURGICAL PATIENT QUESTIONNAIRE LAST NAME FIRST NAME DATE OF BIRTH DIETARY HISTORY Please mark the types of food that you eat a lot: o Carbs o Fatty/fried foods o Fast food o Buffet restaurants o Vegetables o Fruits o Snacks Do you keep a food diary? o Yes o No If you count calories, how many calories per day? Are you on meal replacements (shakes and bars)? o Yes o No What triggers excessive eating for you? o Stress o Sadness o Loneliness o Boredom o Watching TV o Late night o Binging o Social Tell us about your level of physical activity and exercise: Activity Level (0-none, 10-very active): Hours of exercise every week What kind of activity? o Walking o Running o Biking o Water exercise o Other What are your own reasons to lose weight? 1._ 2._ 3._ Mentally, where are you at this moment regarding weight loss plans? How willing are you? (5 being most willing) How ready are you? (5 being I am ready now) How able are you? (5 being very able) What is your stress level at present? On a scale of 0-10, I feel I am at (0-not stressed, 10-very stressed) Have you ever suffered from any of the following conditions? o Glaucoma o Seizures o Thyrotoxicosis o Panic attacks o Problems with heart rhythm that required treatment o Bulimia or anorexia nervosa o Alcohol dependence o Morphine dependence o Other drug abuse problems For female patients only: Are you pregnant or planning to be pregnant soon? o Yes o No Are you using effective birth control? o Yes o No Are you breast feeding? o Yes o No Please check boxes for symptoms that are recent or significantly bothering you. o Unexplained weight loss o Fever o Chills o Fatigue o Blurred vision o Double vision/diplopia o Eye pain o Sinus problems o Nose bleeds o Ear ringing o Hearing loss o Mouth or tongue lesions o Chest pain o Irregular heart beats/palpitation o Heart murmurs o Leg pain o Lef/foot ulcers o Leg swelling o Abdominal pain o Nausea o Vomiting o Constipation o Diarrhea o Blood in stools o Hernia o Difficulty urinating o Blood in urine o Problems with bladder control o Arthritis o Joint pain and stiffness o Gout o Degenerative disc disease o Low back pain o Breast lumps o Breast pain o Nipple discharge o Skin rashes o Moles o Dizziness o Syncope/Fainting o Seizures o Headaches o Weakness in arms or legs o Tremors o Tingling o Anemia o Bruising o Lymph node enlargement/lumps in the axilla or groin o Shortness of breath o Chronic cough o Wheezing o Severe night sweats o Excessive phlegm o Depression o Anxiety o Panic attacks o Memory problems