Download Forms

Our forms section provides you with several forms that you will wish to download and complete before visiting our office. Completing these forms before your visit will save you time and ensure that you have all of the necessary documents available for our medical team to review.

 

Forms

  1. Financial Policy
    Financial Policy
  2. HIPAA Notice
    Our privacy and HIPAA compliance policy
  3. One Year Maintenance Plan
    Terms of the maintenance plan for patients who have undergone the Laparoscopic Adjustable Gastric Band (“Lap-Band”) and are post-op ONE YEAR FROM THE DATE OF SURGERY.
  4. Receipt of Privacy Notice
    Acknowledgment of Receipt of Privacy Notice
  5. Status Change First Year post op
    Terms of the yearly maintenance plan for patients who have undergone the Laparoscopic Adjustable Gastric Band (“Lap-Band”) surgery and have had an insurance status change
  6. Verification of Insurance Coverage
    Required to determine whether your policy includes coverage for the Lap-Band surgery
  7. Weight Loss Program Tax Deductions
    Internal Revenue Service policy (IRS Ruling 202-19)on deducting the cost of a weight-loss programs as a medical expense.