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 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 Insurance Review Form, 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 held at the post office for lack of postage.



Self-Pay Pricing Self-Pay Pricing

Pricing for Insured Patients Pricing for Insured Patients

Patient Profile Packet Patient Profile Packet
You must complete and send this form to us, along with the Insurance Review Form and the Eating Questionnaire, to start your process.

Eating Questionnaire Eating Questionnaire
Complete this form and send along with the Patient Profile Packet and the Insurance Review Form to start your process.

Program Introduction Letter Program Introduction Letter

Step-by-Step for Weight Loss Surgery Step-by-Step for Weight Loss Surgery
This form gives you a visual road map of the steps you must take on your road to weight loss surgery.

Insurance Review Form Insurance Review Form
Please fill out this form if you have any insurance except Medicare or Medicaid.