MRC | Bariatric Referral

Requester Information

Referred By

Name of person submitting referral

First & Last Name

E-mail Address

Phone Number

Call back number if there are questions about the referral

### ###-####

Fax Number

Fax number for communications

### ###-####

Patient's Name First & Last Name

Member/Patient ID

Eligibility Start Date MM / DD / YYYY Eligibility End Date MM / DD / YYYY

Patient's Date of Birth MM /DD /YYYY

Patient's Height Patient's Weight

Patient's Social Security Number ###-##-####

Patient's Address

Street Address

City

State / Province / Region

Postal / Zip Code

Patient's Primary Phone ### ###-#### Best Time to Call Cell Home Work

Patient's Secondary Phone ### ###-#### Best Time to Call Cell Home Work

Patient's E-Mail Address

Primary Care Provider Title, First & Last Name

Primary Provider's Phone Number ### ###-####

Surgeon Title, First & Last Name

Surgeon's Phone Number ### ###-####

Surgery Facility Name

Surgery Facility's Phone Number ### ###-####

Patient Care Coordinator at Facility/Surgeon's Office First & Last Name

Patient Care Coordinator's Phone Number ### ###-####

Procedure Type

Please choose a Procedure Type

Lap Band

Bypass

Sleeve Gastrectomy

Questions, Comments, Additional Info, etc.