2093  Henry  Tecklenburg  Drive,  Suite  202              Charleston,  SC  29414            Phone  (843)958-­‐2590  www.rsfh.com/bariatrics  

“Healing  all  people  with  Compassion,  Faith  and  Excellence”  

Primary  Care  Physician  Worksheet  Patient  Name:  __________________________________________  DOB:____________  

Thank  you  for  assisting  this  patient  with  gathering  the  required  information  he/she  will  need  to  continue  the  registration  process  for  Bariatric  Surgery.  We  appreciate  the  opportunity  to  work  with  you  in  treating  the  disease  of  morbid  obesity.    

Physician  Name:  ___________________________________________   Date:  _____________________  

Clinic/Practice  Name:  ___________________________________________________________________  

Address:  _____________________________________________________________________________  

Phone:  _____________________________________   Office  Contact:  __________________________  

Letter  of  Medical  Necessity  We  will  need  a  letter  of  medical  necessity  from  you  in  order  to  process  your  patient’s  request  for  surgery.  He/she  should  have  a  sample  letter  in  the  packet  of  information  he/she  received  from  our  office.     Completed  Letter  of  Medical  Necessity;  returned  to  patient     Completed  Letter  of  Medical  Necessity;  faxed  to  (843)402-­‐1972  

Preoperative  Assessment  and  Evaluation  In  order  to  expedite  the  process,  your  patient  must  eventually  have  the  following  tests  to  ensure  that  he/she  is  not  placed  in  any  unnecessary  risks  in  pursuing  the  option  of  weight-­‐loss  surgery.     Patient  is  scheduled  to  have  his/her  BONE  DENSITY  TEST  on  ____/____/____     Note:  Bone  density  only  needed  on  Post-­‐menopausal  patients.    (Forearm  or  Ankle  scan  will  suffice  for  test.)     Patient  is  scheduled  to  have  his/her  THYROID  PANEL  on  ____/____/____  If  you  have  any  questions  regarding  these  preoperative  tests,  please  call  Gwen  at  (843)  958-­‐2590.  Medical  Documentation  of  Weight  for  the  Past  Five  Years  In  order  to  better  understand  the  history  and  struggle  your  patient  has  had  with  excess  weight,  and  to  satisfy  the  requirements  of  most  insurance  providers,  we  will  need  documentation  of  his/her  weight  for  the  past  five  years.  

Year   Weight  2014    2013    2012    2011    

 Patient  Height:       ft.   in.  

 Certified  by:  ________________________________________________  on  _______________________       Physician  Signature               Date  

Notice:  This  form  must  be  completed  and  returned  with  the  patient’s  packet  of  registration  materials  or  faxed  to  Roper  St  Francis  Bariatric  and  Metabolic  Services  at  (843)402-­‐1972  before  the  patient’s  request  for  surgery  can  be  processed.  Thank  you  for  your  time  and  cooperation.  

Letter  of  Medical  Necessity  

 

2093  Henry  Tecklenburg  Drive,  Suite  202              Charleston,  SC  29414            Phone  (843)958-­‐2590  www.rsfh.com/bariatrics  

“Healing  all  people  with  Compassion,  Faith  and  Excellence”  

Sample  

Below  is  a  sample  letter  that  your  referring  physician  might  write  in  order  to  assist  with  your  insurance  submission  and  approval.  Feel  free  to  share  this  with  your  referring  physician  in  order  to  expedite  your  progress.    Although  the  letter  does  not  have  to  be  exactly  as  stated  below  it  is  important  that  it  state  your  physician  clears  you  for  surgery.    

 

Date:  Today    To  Whom  It  May  Concern:    Please  accept  this  letter  as  a  formal  request  for  approval  of  Bariatric  Surgery  for  my  patient,  Mr.  John  Doe.  He  has  been  a  patient  of  mine  for  more  than  10  years  and  has  struggled  to  lose  weight.  He  has  personally  tried  many  diets,  including  the  American  Heart  Association  diet,  Dexatrim,  the  grapefruit  diet,  the  cabbage  diet,  Weight  Watchers,  Nutri-­‐System  and  Optifast.  He  has  been  under  Dr.  Smith’s  care,  on  Miami  Beach,  undergoing  his  diet  with  the  help  of  B12  and  thyroid  treatment.  All  have  initially  shown  promise,  but  ended  in  failure.    John  has  been  diagnosed  with  morbid  obesity,  bordering  on  super  obesity  (code  278.01).  His  BMI  is  at  51.2.  He  has  been  diagnosed  with  Sleep  Apnea  and  currently  uses  a  CPAP  machine  for  breathing  assistance.  His  energy  level  had  decreased  steadily  in  the  past  3-­‐5  years  and  has  difficulty  breathing  when  doing  any  exercises.  Just  in  the  past  few  months,  his  blood  pressure  has  decreased.  His  health  is  being  greatly  affected  by  carrying  his  excess  weight  and  I  am  highly  recommending  immediate  action  to  eliminate  this  excess  weight,  which  threatens  his  life.    I  have  referred  him  to  Dr.  “Bariatric  Surgeon’s  Name”,  who  specializes  in  bariatric  surgery  at  Roper  St  Francis  Bariatric  and  Metabolic  Services  in  Charleston,  South  Carolina.  Mr.  Doe  has  contacted  them,  attended  their  informational  seminar  and  agrees  with  me  that  this  is  the  only  way  to  correct  the  situation.  I  agree  with  this  medical  decision  and  have  cleared  this  patient  medically.    Should  you  have  any  questions  regarding  this  recommendation,  please  call  me  at  (123)  456-­‐7890    Dr.  E.  Smith