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Contact Form
Denied Medical or
Surgical Treatment
     IF YOU BELIEVE YOU'VE BEEN WRONGFULLY DENIED MEDICAL OR SURGICAL TREATMENT OF YOUR OBESITY OR MORBID OBESITY, WE NEED SOME INFORMATION TO ASSESS WHETHER AND HOW WE CAN BEST HELP YOU. (eg; IF YOU ARE INTERESTED IN APPEALING A DENIAL OF BARIATRIC SURGERY.)

(THIS FORM IS ENCRYPTED ON A SECURE SERVER FOR YOUR PRIVACY)

     Please take the time to fill out this form COMPLETELY and follow the instructions at the end. You will receive an email from us confirming our receipt of your information and a personal telephone call from the office to further discuss the matter once we’ve evaluated this material. Thank you for your cooperation.

Prefix  
Name  
Street address  
Address (cont.)  
City  
State/Province  
Zip/Postal code  
Country  
Work Phone  
Home Phone  
FAX  
E-mail  
How did you hear about us?
 
What kind of treatment has been denied?
 
Medical
 
Surgical
If Surgical: What kind of Surgery has been denied?
 
Gastric Bypass
 
Lap-Band
 
Duodenal Switch
 
Vertical Banded Gastroplasty
 
Mini Gastric Bypass
From what medical or surgical program were you attempting to obtain treatment?
 
Please identify the insurance company, HMO or self-insured plan which denied the treatment.
 
Please provide us the exact (or your best approximation) of the
date of the denial.
 
-- mm/dd/yy
  
Is the denial in writing?
 
Yes
 
No
 
Don't Know
What is the basis of denial?
 
Not Medically Necessary
 
Contract Exclusion
 
Not A Network Provider
 
Insufficient diet history
 
Don't Know
Has there been a appeal done by either you or your health care provider?
 
Yes
 
No
 
Don't Know
Is this insurance obtained through someone's employment?
 
Yes
 
No
If yes, who is that employer?
 
Please identify and describe yourself:
Age  
Gender  
Male Female
Height  
Weight  
Please indicate which (if any) health issues you have which are or may be related to your weight:
 
Diabetes
 
Hypertension (High Blood Pressure)
 
Sleep Apnea
   
Is this documented with a formal sleep study?
   
Yes
   
No
 
Degenerative Joint Disease
 
Depression
 
Urinary Stress Incontinence
 
Gallbladder Disease
 
Cardiovascular Disease
 
Osteoarthritis
 
Gastro-Esophageal Reflux
 
Dyslipidemia
 
Idiopathic Intracranial Hypertension
 
Lower Extremity Venous Stasis Disease
 
Others
 
Comments:
   
    
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Obesity Law & Advocacy Center
1392 East Palomar Street
Suite 403-233
Chula Vista, CA 91913
 
 
 
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Mail Address: Obesity Law & Advocacy Center, 1392 East Palomar Street, Suite 403-233, Chula Vista, CA 91913
Telephone:  619.656.5251 FAX:  619.656.5254
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