Personal Letter

Please write a personal letter that you can use to express how your weight problem has affected your life.

Financial Policy

Payment of Your Bill

  • Southern Indiana Surgery, Inc. participates with the following insurance carriers: SIHO, Sagamore,
    Anthem, Encore, Champus (TriCare), Medicare and Medicaid. This means that we agree to accept
    your insurance company’s allowable charge. We will also comply with state requirements filing for
    workers' compensation claims.
  • Patients referred by Volunteers In Medicine will be responsible for a nominal fee at the time of the
    office consultation. This fee must be paid in advance of your appointment. You may discuss the fee
    amount with any of our billing staff.
  • We will file with your insurance company for insurance carriers with whom we do not participate;
    however, you may have some charges that fall “out of network” that may be your responsibility.
  • You are responsible for your bill. We will expect payment from you regardless of any divorce
    decree or court orders regarding payment of medical bills.
  • We expect all patients to pay deductibles and co-payments at the time of their office visits.
    If you are uncertain as to what your co-payment will be, we will be happy to give you an estimate
    prior to your visit. You may also contact your insurance company for information.
  • A fee of $20.00 may be charged for any checks returned to us from your bank.
  • We will attempt to discuss your surgery charge and what you will be expected to pay after
    insurance at the time your surgery is scheduled. Please remember this will be only an estimate
    of your charges. For emergency procedures, we will discuss the estimated amount you may owe
    at the time of your follow up visit. You may also contact our staff at any time should you want to
    discuss this earlier. In order to make this possible, you must provide our office with your insurance
  • All patient due accounts are expected to be paid within a reasonable period of time. Any
    account left unpaid or without adequate discussion with our staff, may be subject to referral
    to a collection agency.


  • Patients are asked to notify Southern Indiana Surgery, Inc. within 24 hours of their scheduled
    appointment of their inability to keep an appointment.
    Patients who fail to keep their appointments
    may be subject to a fee of $25.00 if proper notification is not given. This fee will be expected to be paid
    by the patient and is not reimbursable by any insurance carrier.

Authorization for the Use or Disclosure of Protected Health Information

As required by the Health Insurance Portability and Accountability Act of 1996 Southern Indiana Surgery Inc. may not use or disclose your health information except as provided in our Notice of Privacy Practices without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information described herein. You may revoke this authorization at any time by signing and dating the revocation section.

Authorization Section

  • I, hereby authorize the of the following health information that pertains to me:
  • For the following purpose(s): PERSONAL USE
  • I authorize the following persons to make these disclosures of my health information: S.I.S.
  • I authorize the following persons to receive these disclosures of my health information:
  • I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected.
  • I understand that I may revoke authorization at any time by signing the revocation section of my copy of this form. I further understand that any such a revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization.
  • I understand that this authorization will automatically expire on:
  • I understand that I am under no obligation to sign this authorization. I further understand that my ability to obtain treatment, my eligibility for benefits, etc. will not depend in any way on whether I sign this authorization or not.
  • I understand that I have a right to inspect and to obtain a copy of any information disclosed pursuant to this authorization.

Revocation Section

Patient Questionnaire Post Information Seminar

Instructions: This questionnaire is given for your completion to indicate to your surgeon and your insurance carrier that you understand the information that has been presented to you, and that you agree to follow the dietary and life-style changes that are required by the program. If you answer any question incorrectly, it will alert your surgeon to review this information with you, and you will be retested until the doctor is satisfied that you understand the material/concepts involved. Please circle the answer you choose as correct, and fill in any blanks with the information you believe to be true.

True False Question
1. I have been given a guarantee that I will lose weight and that the weight loss will be permanent.
2. It is possible that I could require additional care that could keep me in the hospital on either a short or long-term basis having obesity surgery.
3. Sometimes after obesity surgery it could be necessary to have another operation due to such problems such as bleeding, hernias, ulceration, bursting of sutures/stitches or stables, leaking, blockage of intestines or stomach, or other unforeseen medical conditions.
4. I am aware that obesity surgery is a very serious procedure and I am seeking it for medical and not cosmetic reasons.
5. On average, approximately 1 to 2 patients of every one hundred die from having obesity surgery.
6. I am aware that I will have usual post-operative discomfort experienced by most surgical patients for the first few days after having obesity surgery.
7. I understand that obesity surgery is performed on the stomach and/or intestines, and that staples will be used as part of this procedure, and that it is possible for the stables or suture lines to leak and result in infection or communication (fissure) between the stomach, intestines, or skin.
8. Blood clots seldom occur after having obesity surgery, and they are never a serious cause for concern.
9. I agree to walk as I have been instructed to do even after going home from the hospital to assist in avoiding blood clots and accomplishing weight loss.
10. It is important to eat foods high in protein such as fish, chicken, and dairy products because I am at risk for malnutrition after obesity surgery.
11. I understand that I will be advised by my doctor to take nutritional supplements such as vitamins and mineral, and those could include vitamin injections, for the rest of my life and I agree to do as directed.
12. I understand that I may be subjected to vomiting especially if I do not follow my diet and I agree to follow my dietary instructions for the rest of my life.
13. I understand that all medical problems always get better after obesity surgery.
14. I agree to have periodic nutritional assessments for the rest of my life.
15. I understand that some people become seriously depressed after having obesity surgery and I agree to notify my surgeon if I begin to feel very down or depressed.
16. I agree to remain on full liquid foods such as strained soups, yogurt, and low-fat cottage cheese for at least 6 weeks after having surgery, or longer if so instructed by my doctor/dietitian.
17. I understand that I will never be able to eat the way I did before surgery, and that I will be required to monitor my caloric intake to achieve and maintain my desired weight loss.
18. I agree to keep a food-exercise journal of what I eat and of my activity. I will bring it to my dietitian/MD on my scheduled periodic visits.
19. I understand that some people may become anorexic (not wanting to eat) after obesity surgery, I agree to seek help from my surgeon if that happens.
20. I agree to contact my surgeon if I have any medical problems even if they occur before I am scheduled to go for my check-up.
21. I agree to keep all my doctor's appointments after obesity surgery because I will be required to have periodic check-ups for the rest of my life.

By signing this I certify that I took this test myself without any help during the exam.

Pre-operative Patient Agreement - Tobacco and Illicit Drug Free

I, have attended an information session with the Bariatric Center at Columbus Regional Health. I understand the Bariatric Center at Columbus Regional Health strives for each patient to live a healthy lifestyle and therefore requires all bariatric patients to be tobacco and illicit drug free for a period of 6 weeks prior to being considered as a surgical candidate. Being free from these substances reduces my risk for DVT, pulmonary embolism as well as wound infection; all of which could result in loss of life. I understand these requirements and agree to be tested for cessation of these substances. Failure to comply with these requirements will result in cancellation of my surgery.

For assistance with cessation please request more inforamtion from your primary care provider. For nicotine cessation you may need to be treated with a non-nicotine replacement option.

Pre-operative Patient Agreement - Support Group Attendance

I, have attended an information session with the Bariatric Center at Columbus Regional Health. I understand the Bariatric Center at Columbus Regional Health strives to be pro-active in all aspects of surgical treatment and recommends potential bariatric patients to attend a minimum of two support groups prior to surgery. I understand these recommendations and will do my best to attend at least two support groups prior to surgery. Failure to comply with this recommendation may result in cancellation or postponement of my surgery.

For an up-to-date list of support groups please visit our program website at or call the office at 812-418-3512.