New Patient Information Form

Thank you for your interest in Coastal Center for Obesity

The online New Patient Information Form is provided for your convenience. If you need assistance or have any questions please don't hesitate to contact us by phone or email. We are here for you and want to help make your experience with Coastal Center for Obesity a positive one.

The Staff at Coastal Center for Obesity
800 475 3383
info@coastalobesity.com

Insurance Card

In addition to submitting this questionnaire, please send us a copy of the front and back of your insurance card. You may mail or fax this copy to us.


 

Pre Op Questionnaire

Please fill out all the questions as completely as possible. Plan to spend 20 to 40 minutes completing this questionnaire. When finished click the "Submit" button at the bottom of the page to process your information. Items in Red are required to be filled in.

All information included on the Pre-Operation Form will be deemed "Protected Health Information" and may be released to insurance payors, health care providers or other "Business Associates" of Coastal Center of Obesity in accordance with Title 45, Code of Federal Regulations, Section 160.103..


ex. xxx-xxx-xxxx
ex. xxx-xxx-xxxx
(digits only, no dashes)
(please provide a number even if you are unsure of the total)
(answer with a number even if it is only a guess)

INSURANCE

Please give us all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, supply information of all.

In order to submit a claim for payment to us for services covered under you policy, we must have your authorization to release medical information to your insurance carrier.

Medicare and Medicaid: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me. I request that payment under the medical insurance program be made either to me or to Milton L. Owens, M.D., Inc. on any bills for services furnished me by Milton L. Owens, M.D., Inc. during the next 12 month period.

All Other Insurance: I hereby authorize Milton L. Owens, M.D. , Inc. to submit a claim to my insurance carrier or its intermediaries for all covered services rendered by the physician(s) and authorize and direct my insurance carrier or its intermediaries regarding services rendered.

Payment Default: In the event of payment default, I agree to be responsible for any and all collection fees.




ex. xxx-xxx-xxxx
 


EMPLOYMENT


FAMILY PHYSICIAN

ex. xxx-xxx-xxxx

FAMILY HISTORY


DOES ANYONE IN YOUR FAMILY HAVE...


OPERATIONS


ILLNESSES


MEDICATIONS

What medications are you taking? [Do not forget such things as aspirin, cortisone, blood pressure medication, thyroid, tranquilizers, hormones, birth control pills, laxatives, vitamins, etc.]


ALLERGIES


EATING HABITS


SMOKING AND DRINKING


SLEEPING


RESPIRATORY


CARDIOVASCULAR


GASTROINTESTINAL


URINARY


GYNECOLOGICAL


MUSCULOSKELETAL


SKIN


HEAD


MENTAL HEALTH


HEMATOLOGICAL


ENDOCRINE


METHODS OF WEIGHT CONTROL USED IN THE PAST

Doctor Supervised Programs

Traditional Weight Loss Programs

Non-traditional Weight Loss Programs

Self Diets

Popular Diet Programs

Nutritional Programs

Previous Weight Loss Surgery Procedures


CHOICE OF SURGERY


CHOICE OF SURGEON


PATIENT INFORMATION SEMINAR


WHO CAN WE THANK FOR THIS REFERRAL?

Name & Address (if you selected "Physician" or "Coastal Patient")

If you have filled out all of the answers to the best of your knowledge click the Submit button below.



Don't forget to fax or mail us a copy of the front and back of your insurance card.
Fax: 714-997-4449


Psychological and Nutritional Evaluation Forms

Psychological Evaluation Forms Enter Bypass Patient Manual download

Nutritional Evaluation Forms Enter Bypass Patient Manual download