Bariatric Center Georgetown Community Hospital

Forms

Feel free to download the forms below. To begin your process, complete the Patient Profile Packet, the Eating Questionnaire and the IRF - 2010 (Insurance Review Form) and mail to us, along with a copy of your insurance card(s), front and back, to:

Georgetown Bariatrics

1140 Lexington Road, Ste. 230

Georgetown, KY 40324

You may also fax those to us at: 502-570-3719

Note: If you have Medicaid or Medicare (without supplement), you do not need to complete the IRF-2010, but we must have your Patient Profile Packet and a copy of your Medicaid and/or Medicare card(s). Additionally, it will take four (4) stamps to insure the forms are delivered promptly and not help at the post office for lack of postage.

Your Roadmap to Weight Loss Surgery
A visual flow chart explaining each step of a patient's progress.

Cost Breakdown for Insured Patients
This form comprehensively breaks down all fees associated with surgery and pre-operative medical requirements, and when they will be billed.

Self-Pay Pricing
Current Self-Pay pricing for non-insured patients.

Patient Profile Packet with Sleep Questionnaire and Nutrition Inventory
Complete this medical history, sleep and nutritional assessments, and send to us, along with the Insurance Review Form and a copy of your Insurance Card, front and back.

IRF - 2010
Insurance Review Form - to be completed by all patients using private insurance (only exceptions: Medicare without supplement and Medicaid).

Introductory Letter
This form introduces patients to our staff and surgeons and gives contact information.

Eating Questionnaire
This form will help our Psychologist, Dr. Lisa West-Smith, during your Psychological Evaluation. Please be honest and accurate with your answers.