11-Primary Care Physician Worksheet - Charleston, SC Services/Bariatric...
Transcript of 11-Primary Care Physician Worksheet - Charleston, SC Services/Bariatric...
2093 Henry Tecklenburg Drive, Suite 202 Charleston, SC 29414 Phone (843)958-‐2590 www.rsfh.com/bariatrics
“Healing all people with Compassion, Faith and Excellence”
Primary Care Physician Worksheet Patient Name: __________________________________________ DOB:____________
Thank you for assisting this patient with gathering the required information he/she will need to continue the registration process for Bariatric Surgery. We appreciate the opportunity to work with you in treating the disease of morbid obesity.
Physician Name: ___________________________________________ Date: _____________________
Clinic/Practice Name: ___________________________________________________________________
Address: _____________________________________________________________________________
Phone: _____________________________________ Office Contact: __________________________
Letter of Medical Necessity We will need a letter of medical necessity from you in order to process your patient’s request for surgery. He/she should have a sample letter in the packet of information he/she received from our office. Completed Letter of Medical Necessity; returned to patient Completed Letter of Medical Necessity; faxed to (843)402-‐1972
Preoperative Assessment and Evaluation In order to expedite the process, your patient must eventually have the following tests to ensure that he/she is not placed in any unnecessary risks in pursuing the option of weight-‐loss surgery. Patient is scheduled to have his/her BONE DENSITY TEST on ____/____/____ Note: Bone density only needed on Post-‐menopausal patients. (Forearm or Ankle scan will suffice for test.) Patient is scheduled to have his/her THYROID PANEL on ____/____/____ If you have any questions regarding these preoperative tests, please call Gwen at (843) 958-‐2590. Medical Documentation of Weight for the Past Five Years In order to better understand the history and struggle your patient has had with excess weight, and to satisfy the requirements of most insurance providers, we will need documentation of his/her weight for the past five years.
Year Weight 2014 2013 2012 2011
Patient Height: ft. in.
Certified by: ________________________________________________ on _______________________ Physician Signature Date
Notice: This form must be completed and returned with the patient’s packet of registration materials or faxed to Roper St Francis Bariatric and Metabolic Services at (843)402-‐1972 before the patient’s request for surgery can be processed. Thank you for your time and cooperation.
Letter of Medical Necessity
2093 Henry Tecklenburg Drive, Suite 202 Charleston, SC 29414 Phone (843)958-‐2590 www.rsfh.com/bariatrics
“Healing all people with Compassion, Faith and Excellence”
Sample
Below is a sample letter that your referring physician might write in order to assist with your insurance submission and approval. Feel free to share this with your referring physician in order to expedite your progress. Although the letter does not have to be exactly as stated below it is important that it state your physician clears you for surgery.
Date: Today To Whom It May Concern: Please accept this letter as a formal request for approval of Bariatric Surgery for my patient, Mr. John Doe. He has been a patient of mine for more than 10 years and has struggled to lose weight. He has personally tried many diets, including the American Heart Association diet, Dexatrim, the grapefruit diet, the cabbage diet, Weight Watchers, Nutri-‐System and Optifast. He has been under Dr. Smith’s care, on Miami Beach, undergoing his diet with the help of B12 and thyroid treatment. All have initially shown promise, but ended in failure. John has been diagnosed with morbid obesity, bordering on super obesity (code 278.01). His BMI is at 51.2. He has been diagnosed with Sleep Apnea and currently uses a CPAP machine for breathing assistance. His energy level had decreased steadily in the past 3-‐5 years and has difficulty breathing when doing any exercises. Just in the past few months, his blood pressure has decreased. His health is being greatly affected by carrying his excess weight and I am highly recommending immediate action to eliminate this excess weight, which threatens his life. I have referred him to Dr. “Bariatric Surgeon’s Name”, who specializes in bariatric surgery at Roper St Francis Bariatric and Metabolic Services in Charleston, South Carolina. Mr. Doe has contacted them, attended their informational seminar and agrees with me that this is the only way to correct the situation. I agree with this medical decision and have cleared this patient medically. Should you have any questions regarding this recommendation, please call me at (123) 456-‐7890 Dr. E. Smith