Before you begin, we'd like to know if hospital administrators are discriminating against YOUR obesity surgery program?
Click here to help us educate them about reimbursement success.

Chances are you might only remember one or two of the numbers below. If this is the case, then go ahead and fill them in, leaving the rest blank. No need to guess.

You can return at any time to fill in more of the boxes. Thank you for your help!

Please be alert to the fact that the AMOUNT BILLED is, in many cases, NOT the same as the AMOUNT REIMBURSED BY THE INSURER. Hospitals and surgeons invoice for a certain amount, knowing in advance that they will be paid a lesser amount.

If you have any questions and/or if you can obtain the invoicing paperwork from your hospital or surgeon, please email [email protected].



What hospital was the surgery performed at?
Did you pay cash for your entire surgery out of pocket?
Did you finance your entire surgery?
What was your total length of stay at the hospital (how many days were at the hospital in total)?
Did you stay in the hospital's Intensive Care Unit (ICU)? If so, how many days total were you in the ICU?

Provider Type

 Amount Billed

How much did the provider type indicated below charge or try to collect? (this is often more than the  amount received) 		Amount Reimbursed by Insurer

How much did the provider type indicated below actually receive from the insurer (or receive from you as a direct result of payment by insurer) ?		 Your out of pocket expenses

How much did you yourself actually pay the provider type indicated below which was never reimbursed by any insurer?
Surgeon Fees (including consult) $   $   $  
Anesthesiologist Fees $   $   $  
Total Hospital Charges for Surgery $   $   $  
TOTAL $   $   $  


Comments:





Lab/center charges, excluding professional fees (i.e., exclude fee for cardiologist, pulmonologist, etc) Billed by the same hospital that you had surgery at? Amount Billed
How much did the providers of the tests below bill or try to collect? (this is often more than the  amount received)		 Amount Reimbursed by Insurer
How much did the providers of the tests below actually receive from the insurer (or receive from you as a direct result of payment by insurer) ?		 Your out of pocket expenses
How much did you yourself actually pay the providers of tests below which was never reimbursed by any insurer?
Sleep Tests $   $   $  
Cardiac Tests $   $   $  
Pulmonary Tests $   $   $  
Endoscopy Tests $    $   $  
All X-ray / MRI / CT $    $   $  
Other $    $   $  


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