Information to Aid You in Referring Patients
If you are a MaineHealth provider, please enter the referral into EPIC. If not on EPIC, please mail or fax the following information.
- Referral for the evaluation and treatment of morbid obesity (ICD-9 278.01)
- Referral authorization # from the insurance company
- BMI (or most recent height and weight)
- All related diagnoses and comorbidites
- Previous attempts/duration of unsuccessful weight loss
- Demographic Information on the patient (DOB, address, phone number, insurance info)
- Most recent H&P including blood work and medications
Smokers will be required to quit smoking and have a nicotine level drawn and sent to us before their first appointment.