12266 DePaul Drive, Suite 310 St. Louis ... - SSM Health Images/pdfs/st-louis... · Thank you for...

Patient Packet

Your Body. Your Life. Start Today.

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 andnon-surgical program.

Once the attached paperwork is completed it can either be emailed back to us at [email protected] or faxed to 314-622-6453.

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 medical-necessity, 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 43770. 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 314-344-6489.

DPS-2065-948 (3/2018)

SSM Health Weight Management Services12266 DePaul Drive, Suite 310St. Louis, Missouri 63044314-344-6800 Phone314-622-6453 [email protected]

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 procedureor pay in full on the day of your procedure.

• Commerce Bank (No Cost/No Interest) Health Services Financing ProgramTo assist in making your medical bills more manageable, SSM Health offersa zero cost, zero interest health services financing program that spreadspayments out over time. There is NO credit check, NO origination fees and NOpre-payment penalty.

¡ Options Include:§ 24 Month, 0% Interest Financing for balances of $600 - $4,999.99§ 36 Month, 0% Interest Financing for balances of $5,000 - $9,999.99§ 60 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 insurancepayment 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) 989-6789 or by email at [email protected].

PATIENT REGISTRATIONPATIENT INFORMATIONLAST NAME ______________________________________________________ FIRST NAME & INITIAL _____________________________________

ADDRESS ________________________________________________________________________________________________________________

CITY _______________________________________________________ STATE _____________ ZIP _____________________________________

HOME PHONE ____________________________ CELL PHONE ____________________________ E-MAIL ___________________________________

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 INFORMATION1. 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 ________________________

SSM Health Weight Management Services12266 DePaul Drive, Suite 310St. Louis, Missouri 63044314-344-6800 Phone314-622-6453 Faxssmhealthweightmanagement.com

PATIENT MEDICAL QUESTIONNAIREPlease 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.

Name Strength Frequency Purpose When Started

CURRENT MEDICATIONS INCLUDING VITAMINS, OVER-THE-COUNTER MEDICATION, AND INTERMITTENTLY USED DRUGS.(Please list prescription medication first)

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 Procedureso 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 Switcho Adjustable Gastric Bando 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


PAST MEDICAL HISTORY

Illness Date Treatment Outcome

WHAT MEDICAL PROBLEMS ARE CURRENTLY BEING TREATED?

PAST SURGICAL HISTORY

LIST ANY SURGERIES:

Surgery Date Reason Physician

FAMILY HISTORY

Arthritis-rheumatoid

Asthma

Cancer

Coronary Artery Disease

Diabetes

Deep vein thrombosis (DVT/PE)

Heart Failure

Hypercholesterolemia

Hypertension

Migraine

Osteoarthritis

Rashes/Skin Problems

Seizures

Stroke

Thyroid Disease

Mother Father Sister Brother MaternalGrandmother

MaternalGrandfather

PaternalGrandmother

PaternalGrandfather Other


ALLERGIESLIST ALL DRUG ALLERGIES:

Drug Name Reaction

PATIENT MEDICAL QUESTIONNAIRE

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-surgicalDo 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 mightcontraindicate 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.

MENTAL HEALTH BACKGROUND INFORMATION


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? 0 1 2 3 4 5 (5 being most willing) How ready are you? 0 1 2 3 4 5 (5 being I am ready now) How able are you? 0 1 2 3 4 5 (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 nervosao 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 paino Sinus problems o Nose bleeds o Ear ringing o Hearing loss o Mouth or tongue lesionso Chest pain o Irregular heart beats/palpitation o Heart murmurso Leg pain o Lef/foot ulcers o Leg swellingo Abdominal pain o Nausea o Vomiting o Constipation o Diarrhea o Blood in stools o Herniao Difficulty urinating o Blood in urine o Problems with bladder controlo Arthritis o Joint pain and stiffness o Gout o Degenerative disc disease o Low back paino Breast lumps o Breast pain o Nipple discharge o Skin rashes o Moleso Dizziness o Syncope/Fainting o Seizures o Headacheso Weakness in arms or legs o Tremors o Tinglingo Anemia o Bruising o Lymph node enlargement/lumps in the axilla or groino Shortness of breath o Chronic cough o Wheezing o Severe night sweats o Excessive phlegmo Depression o Anxiety o Panic attacks o Memory problems


12266 DePaul Drive, Suite 310 St. Louis ... - SSM Health Images/pdfs/st-louis... · Thank you for...

Documents

Transcript of 12266 DePaul Drive, Suite 310 St. Louis ... - SSM Health Images/pdfs/st-louis... · Thank you for...