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Toll Free: (866) 622-0119

Bariatric Enrollment Packet

New Patients: Bariatric

Dear Patient,

Thank you for inquiring about our practice and surgical treatments for weight loss. Please read this information carefully and thoroughly. In order to enroll in our Bariatric Program and obtain a consultation, we require that all prospective patients complete the packet of forms below.

You will need the free Adobe Acrobat Reader to read/print them.

PLEASE NOTE *You will need to read either Gastric Bypass or Sleeve Gastrectomy options listed on the bottom of this page, in order to fill out some of these forms. The answers to some of the questions asked will be found in these topics.

Individual Forms – PDF Format:

Bariatric Enrollment Packet is found here.

Be Sure all forms are witnessed when required.

Please mail these forms with your phone number to:

Shelby Baptist Medical Center
Bariatric Program
1000 1st North
Alabaster, AL 35007

ALL FORMS MUST BE COMPLETELY FILLED OUT
NOT COMPLETING THESE FORMS WILL DELAY SCHEDULING OF APPOINTMENT

After receiving all completed forms, we will then contact you by letter.

Consultation:

There is a $250 consultation fee for bariatric patients. Note that we assess a new patient consultation fee that covers our initial intake, collecting and processing records for submission to the insurance company for review, precertification of coverage, scheduling, and the surgeon’s consultation.

Insurance?

Please be advised that in many circumstances the initial bariatric consultation is a non-covered expense by insurance. As a courtesy, we will file your surgeon’s evaluation visit with your insurance carrier. If they determine the physician’s evaluation for bariatric surgery is a covered expense, you will be reimbursed the difference between their payment and the consult fee (or your copay, as applicable).

Thank you for all your assistance. We look forward to meeting you in the near future.

Cahaba Valley Surgical Group, P.C. and Shelby Baptist Medical Center

Nondiscrimination Statement:

Cahaba Valley Surgical Group, P.C. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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