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.