Bariatric Surgery Financial Agreement

Candidates for bariatric surgery are required to sign a Bariatric Surgery Financial Agreement. You can review and sign the printable agreement and bring it with you on your initial visit. Below is a summary of the actual agreement.

Candidates must understand that charges related to bariatric surgery may or may not be covered by their insurance provider. You will be required to pay a percentage of the charges at the time of the initial office consultation and before surgery is scheduled. If your insurance company does not require an up-front authorization, you will be required to pay half of the charge before the surgery is scheduled. If your insurance company deems this procedure not medically necessary after the surgery is performed, you are responsible to pay the charges in full.

You must further understand and agree by signing the form that if you have gastric bypass surgery, you will not become pregnant for at least one year after the surgery is performed. However, if you become pregnant, you will not hold any liability of complications that may occur against Paul M. Carter, MD PA.

You must further understand and agree by signing the form that if you have gastric bypass surgery, you will be required to return to Dr. Carter's office for regular check-up appointments (every 6 months). You must understand that lab work is required every 6 months following surgery and you agree by signing the form to be compliant in your follow-up.

You will thereby authorize payment of any insurance benefits directly to Paul M. Carter, MD PA.

Release of your medical records will be granted upon receipt of a signed authorization.