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Insurance Verification Form

Insurance Verification Form

This is not a guarantee of benefits.

As a courtesy Northwest weight loss surgery will be happy to contact your insurance plan to ask for your benefits for the surgical treatment of morbid obesity. 

We would be happy to verify your insurance benefits. Please complete this entire form.

Typically we can contact your insurance and verify benefits within 7 to 10  business days. We highly recommend that you call the insurance company as well; this is not a guarantee of benefits 



Name *
Middle Initial *
Address *
Best Phone Number to Reach you *
E-mail *
Date of Birth *
Height *
Weight *
Health conditions related to weight? *
Primary Care and/or Referring Physician: *
Employer: *
Name of Insurance Provider: *
ID# *
Group# *
Customer Service number off back of card: *

Real Patients, Real Results

He seemed very caring right from the start. I still think that to be the case. The office staff is very friendly and helpful. I really liked the way he introduced...

Laurie - Renton, WA

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Support groups should play an important part in your preparation, recovery and long-term goals. We are here to assist you every step of the way. Email your questions to

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