Bariatric Surgery Program Application 

UnityPoint Clinic Surgery – Fort Dodge Bariatric Surgery Application
Your Information
















Your Primary Care Provider
If you don't have a primary care provider, you must be established or scheduled with one prior to your first visit.






Primary Insurance Information












Additional Questions


Have you ever been seen in the emergency department or admitted to a hospital or treatment facility for any of the following:







Insurance Dislaimer
Many insurance companies have specific requirements that must be met before surgery is approved

Instructions:
  1. Call the customer service number on your insurance card and speak to a customer service representative.
  2. Tell the representative that you would like to check policy benefits for weight loss surgery for morbid obesity.
  3. The procedure will take place at:
    UnityPoint Health – Trinity Regional Medical Center
    802 Kenyon Road
    Fort Dodge, IA 50501
Disclamer: 
  • The UnityPoint Clinic Surgery – Fort Dodge Bariatric Surgery Program is NOT responsible for incorrect inforrmation provided by the insurance company.
  • Completion of this form does not mean that you are approved for weight loss surgery and does not guarantee payment for services. You will be responsible for any charges that your insurance does not cover.


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