Free Insurance Verification

(*) = Required. Please complete the form below and click "Submit Form" at the bottom. As always your contact information will be kept strictly confidential. We will attempt to reply to your inquiry within 48 hours.

First Name: (*)

Last Name: (*)

Email: (*)

Day Phone: (*)

Evening Phone:

Optional: For Easy Verification, please enter your S.S. Number:

Street Address (No P.O. Box):

City:

Postal (Zip) Code:

State/Province:

Country:

I am interested in:

having surgery
making an appointment
getting information

Insurance Company Claims Address:

Insurance Company Phone:

Please enter info and any questions:

Date of Birth (MM/DD/YY): (*)

Age:

Weight:

Height:

I heard about you from:

I would like to be notified via email about:

upcoming seminars/news
new procedures

Many patients want to know whether their insurance will cover the surgery. Get a head start by completing this section:

First & Last Name of Insured Person:

Primary Insurance Provider: (*)

Insurance provider type: (*)

PPOPOSEPO other or don't know
HMO (that has out-of-network benefits)

Relationship of Insured Person to Patient:

Insured Person's Date of Birth:

Insured Person's Employer:

Insured Person's Policy / Member ID#: (*)

Group/Policy/Other #:

Claims / Providers Phone # on Insurance Card: (*)

Other Specialties

Copyright © 2008 - 2010 Weight Loss Centers 1-800-GET-THIN :: 1800-GET-SLIM :: Lap Band Surgery :: Admin Login

Copyright © 2008 - 2010 Weight Loss Centers
1-800-GET-THIN :: 1800-GET-SLIM :: Lap Band Surgery :: Admin Login