Name: Bariatric Surgery
Brand: Insight Wellness Center
Availability: InStock
Rating: 5 (148 reviews)

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1Brief Assessment
Answer a few questions about your preferences.

2Verify Payment Method
Get Pre-Authorized

3Match With A Professional
Free Consultation Request

Consent*

I understand that Insight Wellness Center relies on the medial information I provide for my care. By typing my name below, I acknowledge that the medical information I am providing is accurate and complete.*

Full Name*

Email*

Patient's Date of Birth*

MM slash DD slash YYYY

Address*

Street Address City State ZIP Code

Phone*

Gender Identity*

Full name of primary care physician*

Name of psychiatrist - When last seen - For how long*

Name of psychotherapist - When last seen - For how long*

Have you ever been diagnosed with any of the following? Please select all that apply (Past or present)

Depression

General Anxiety

OCD

PTSD

Eating Disorder

Bi-Polar Discorder

Other

Other*

Any Drug/Medication Allergies?*

Yes

Unknown

Please list all medications to include over-the-counter and dietary supplements/vitamins. Include dosage and frequency.

Please list your current Medications*

Medication List

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Date of recent Lab work

Lab Work

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Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.

Tobacco/Alcohol/Caffeine/Drug Usage

Do you use Tobacco?*

Yes, I smoke daily

Yes, I smoke sometimes

No, I quit smoking

No, I have never smoked

Do you Vape?*

Yes

Do you use Cannabis?*

Yes, I use it daily

Yes, I use it sometimes

No, I quit

No, I have never used it

I use CBD - NO THC

How often do you consume Alcohol?*

I don't drink

1-4 drinks/year

1-4 drinks/month

1-2 drinks/day

3-4 drinks/day

5+ drinks/day

How often do you consume Caffeine?*

I don't drink

I don't use caffeine

1-4 cups/month

1-2 cups/day

3-4 drinks/day

5+ cups/day

Please list all non prescription drug use names and frequency.

Is there any information that you feel may aid in your evaluation?

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Would you like to proceed with method of payment or insurance pre-authorization?*

Yes

Your method of payment will not be stored unless you decide to have services with Insight Wellness Centre.

Yes, I would like to subscribe to the newsletter.

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Select your payment method*

Health Insurance

Private Pay

Insurance and Billing Pre-Authorization Registration Form

Completing your preferred method of payment and insurance verification before your appointment expedites the registration process, ensuring you're seen faster and more efficiently.

Please complete all required fields. Once completed your information will be submitted securely and verified to ensure your insurance is accepted by the provider including coverage and benefit details. If your provider is Out-of-Network, claims will be submitted on your behalf, but you will be responsible for the full rate at time of service. Any payable benefits will be reimbursed to the subscriber of the plan. You will receive quote of benefits and rates via email confirmation from our Billing Manager, Victoria House [email protected] so that you know your account is ready for services with the provider you have been assigned.

First of all, who may we thank for referring you to us? Please jot their name here:

Demographic Information of Patient (Required, please be as complete and accurate as possible)

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Name*

First Last

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Address*

Street Address City State ZIP Code

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Phone*

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Other Phone(Optional)

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Email*

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Date of Birth

MM slash DD slash YYYY

Insurance Carrier Name*

Anthem/BX (OON)

Beacon (Chevron/PG&E/other-OON)

Tricare/HNFS

Medicare

UHC/UBH/UMR/Optum (no Medicare-type plans accepted)

Blue Shield CA/BXBS (OON)

HealthNet/MHN

Aetna (OON)

Contra Costa Health Plan

Kaiser (Referral authorization required)

Other

"Other" Insurance Name

KAISER
In order to get your account confirmed for scheduling:
1) please conduct your intake phone interview with Veronica Penagos; she will assign a therapist to you.
2) Please request a referral authorization from your Kaiser PCP to your assigned provider and/or
3) complete this form with your Kaiser MRN# so we can put your on a future appointment hold so Kaiser can link you to this practice for retro-authorization.
NOTE You must complete a recent Kaiser clinical screening with a Kaiser clinical manager in order to proceed.

Policy Holder's Name

Policy Holder's Date of Birth

MM slash DD slash YYYY

Policy Member ID#

Group Number

Copay Amount

Deductible

Deductible Met?

Yes

Unsure (don't worry if you're not sure, this will be verified for you)

Relationship to Patient

Self

Spouse

Child

Do you have the image of you insurance card (if you select yes you will have to upload it).

Yes

Please upload an image of your Insurance Card here (FRONT):*

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Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Please upload an image of your Insurance Card here (BACK):*

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Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Secondary Insurance (Optional, but if you have another active plan please provide the info below)

Secondary Insurance (Optional, but if you have another active plan please provide the info below)

Secondary Insurance

Secondary Insurance (Optional, but if you have another active plan please provide the info below)

Insurance Name

Policy ID#

Policy Holder's Name

Date of Birth

MM slash DD slash YYYY

Upload an image of Secondary Plan ID Card (if not already attached above):*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Do you have an EAP authorization or plan to use EAP benefits--please complete the info below so we can verify?

Do you have an EAP authorization or plan to use EAP benefits-please complete the info below so we can verify?*

Yes

EAP AUTH#

AUTH EFFECTIVE DATE

AUTH EXPIRATION DATE

NUMBER OF SESSIONS AUTH'D

We currently only accept EAP referrals from MHN, upon confirmation of benefits and you are assigned a therapist and an initial appointment date, you will need to contact MHN to ensure the authorization is properly assigned to Insight Wellness Center and the therapist's name who you will be seeing.

Payment Information and Agreement to Pay

Please provider your preferred method payment and sign at the bottom to authorize the use of your information to be pay for agreed upon services per your agreement with Insight Wellness Center. Please ensure the information provided is accurate and that the credit card or Bank ACH (checking account optional) account provided has funds available for use.

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Type of Credit Card:*

Master Card

Visa

Discover

American Express

HCA Card

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Name on Card*

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Card Number*

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Expiration Date (Format MM/YYYY)*

MM slash DD slash YYYY

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Billing Zip Code (NOT the 3-dig Code; Zip Code where bills are mailed)*

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Routing Number (9 Digits Only)*

Alternatively, you may use your Bank Account's Routing and Account number like an "e-Check". If you would prefer this option, please complete the details of your account below. To find the Account Number and Routing Number, look at the numbers at the bottom of a physical check.

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Account Number (Include all leading zero's if any)*

Financial Responsibility & Release of Information Agreement (Signature Required)

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By Signing below, I agree to the following policies of Wellness Center's practice and services they provide:*

1) I authorize use of this form to convey my personal and insurance information to Insight Wellness Center
2) I authorize release of information to my insurance company for claims billing purposes.
3) I authorize insurance payments directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; Missed session fee=$50 for Medicare plans and $100 for other insurance or Private Pay accounts.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.

I agree to these terms.

Signature of Responsible Party (use mouse or finger to sign)*

If an intake coordinator/representative completes

If an intake coordinator/representative completes this form on my behalf, I authorize them to sign with an 'X' on my behalf.

Name of Intake Representative Filling Out This Form*

First Last

Date*

MM slash DD slash YYYY

If someone else, besides the patient/responsible party

If someone else, besides the patient/responsible party, is completing this form and is financially responsible for any balance due, please add your contact info here:

Name of Responsible Party if other than Patient named above*

First Last

Address*

Street Address City State ZIP Code

Phone*

Email*

Relationship with patient/client

Credit Card Authorization form

Please enter your credit card for copays, deductibles, Private Pay or Out of Network.

Thank you for coming to Insight for Wellness Center. In order to better serve you, we have initiated a new way of collecting payments. This will allow us, as your healthcare providers to focus on treatment during our time together instead of financial issues that can be stressful and time-consuming.

Please complete all required fields. Once completed your information will be submitted securely to our Billing Department Manager, Victoria House. This information will be used to create your StoredPay Account and a separate email (from [email protected]) will be forthcoming to confirm your authorization to use this payment information to process balances due for Copays, Deductibles and Cash balances due per your rate agreement.

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Name*

First Last

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Address*

Street Address City State ZIP Code

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Phone Number*

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Other Phone

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Email*

Select Credit Card or Account Checking Options:*

CREDIT CARD

ACCOUNT CHECKING

CREDIT CARD

Card#*

Exp. Date

Billing Zip Code for this Account*

Name as it appears on Card*

Additional Information

Additional

Routing Number*

Account Number*

Financial Responsibility & Release of Information Agreement (Signature Required)*

1) I authorize use of this form to convey my billing information to House Medical Billing Service; Victoria House, Billing Manager/Owner.
2) I authorize release of information to my insurance company (if applicable) for claims billing purposes.
3) I authorize insurance payments (if applicable) directly to the provider of service when they are considered a "Network Provider" or when my benefits allow it.
4) I understand I am responsible for the full amount of my bill for services provided. Cash, Check and Credit Card are accepted.
5) There is a 24-HOUR cancellation policy. I understand I will be billed IMMEDIATELY for the cash rate if I do not cancel at least 24 hours in advance of my appointment. Insurance does not cover no show/late cancellations; you will be expected to cover the amount insurance would pay or the normal rate you would pay for attending your appointment.
6) In the event that my account goes unpaid for more than 90 days I acknowledge it may go to collections and I will be responsible for the balance due plus 30% collection fee.
7) Payment for services is ultimately my responsibility as insurance cannot be guaranteed.

I agree to the above 1 to 7 policies of Insight Wellness Center's practice and services they provide

Signature of Responsible Party (use mouse or finger to sign)*

ACCOUNT CHECKING

Routing Number*

Account Number*

Financial Responsibility & Release of Information Agreement (Signature Required)*

I agree to the above 1 to 7 policies of Insight Wellness Center's practice and services they provide

Signature of Responsible Party (use mouse or finger to sign)*

Check if you are filling this form on behalf of someone

Check if you are filling this form on behalf of someone else and you have the consent from the party in initiating this inquiry to sign on their behalf.

Full Name*

Phone*

Email*

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If someone else, besides the patient, is completing this form and is financially responsible for any balance due, please add your contact info here:

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Name of Responsible Party if other than Patient named above

First Last

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Address

Street Address City State ZIP Code

Please choose your preferred payment method.**

Health Isurance

Private Pay

Please direct any future billing questions to Victoria House, Billing Manager via email [email protected] Or Call (530) 474-6094

Free Appointment Consultation Request

We have included several ways to contact us. Please give us a call, send an email, or simply fill out the form on this page. We look forward to speaking with you.

Preferred Contact Method*

Schedule a Call

Connect via Email

Full Name*

Phone*

Email Address*

First Preferred Call Back Date*

MM slash DD slash YYYY

Second Preferred Call Back Date*

MM slash DD slash YYYY

Choose Your Preferred Callback Times (Select at least two)*

09:00 AM - 10:00 AM

10:00 AM - 11:00 AM

11:00 AM - 12:00 PM

12:00 PM - 01:00 PM

01:00 PM - 02:00 PM

02:00 PM - 03:00 PM

03:00 PM - 04:00 PM

04:00 PM - 05:00 PM

05:00 PM - 06:00 PM

Is there any other information you would like us to know or specific contact instructions you prefer.*

Feel free to provide a description of how we can assist you, avoiding overly detailed or highly sensitive information to ensure privacy. We will do our best to get back with you as soon as possible.

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Preoperative Psych Evaluation Bariatric Surgery Form

Tobacco/Alcohol/Caffeine/Drug Usage

Insurance and Billing Pre-Authorization Registration Form

Secondary Insurance (Optional, but if you have another active plan please provide the info below)

Section Break

Credit Card Authorization form

CREDIT CARD

Additional

ACCOUNT CHECKING

Section Break

Free Appointment Consultation Request

We have included several ways to contact us. Please give us a call, send an email, or simply fill out the form on this page. We look forward to speaking with you.