11851 Jollyville Rd #104
Austin, TX 78759
512-257-2425

Call Us at (512) 257-2425

Free Insurance Verification

Would you like to know if your Health Insurance covers “Weight Loss Surgery”?

Please fill out the following form. Austin Bariatric staff will call your Insurance company, verify benefits and will call you back.

Instructions:

  • Please fill out all the fields adequately. All fields are required.
  • Please list all Insurance companies even if they don’t cover weight loss surgery. If you don’t have secondary insurance please type “None” in the fields.
  • Please allow us 2 business days to respond back. Our staff will call you to explain the benefits and additional details.

First Name (* Required)

Last Name (* Required)

Gender
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Date of Birth (* Required)

Primary Phone number (* Required)

Additional Phone Number

Mailing Address (* Required)

City (* Required)

State

Zip (* Required)

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How did you hear about us?

Procedure interested in.

Policy holder

Relationship to policyholder

Name of Primary Insurance company

Insurance company phone number

ID or Policy number

Group number

Name of Secondary Insurance company

Policy holder

Relationship to policyholder

Insurance company phone number

ID or Policy number

Group number

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