Bariatric Surgery Program Application 

Trinity Weight Management Specialists - Moline Bariatric Surgery Application
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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. UnityPoint General Surgery Clinic 600 John Deere Road, Suite 600, Moline, IL 61265 is where the surgery will take place.
Disclamer: 
  • The UnityPoint 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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