Bariatric Center Georgetown Community Hospital

Forms

Feel free to download the forms below. To begin your process, complete the Patient Profile Packet 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).

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.