Bariatric Surgery Insurance Approval Checklist Form
Submit all required information to request insurance pre-approval for bariatric surgery.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Provider
*
Please Select
Aetna
Blue Cross Blue Shield
Cigna
UnitedHealthcare
Humana
Other
Insurance Policy Number
*
Type of Bariatric Procedure Requested
*
Please Select
Gastric Bypass
Sleeve Gastrectomy
Adjustable Gastric Band
Biliopancreatic Diversion
Other
Referring Physician Name
*
Required Documentation Status
*
Primary Care Referral Letter
Psychological Evaluation
Nutritional Assessment
Pre-Operative Lab Results
Checklist: Standard Insurance Requirements
*
BMI meets insurance criteria
Proof of weight loss attempts
Documented comorbidities (e.g., diabetes, hypertension)
No contraindications for surgery
Contact Email for Approval Updates
*
example@example.com
Submission Notes or Additional Information
Submit Checklist
Should be Empty: