AXIS HEALTHCARE PROFESSIONAL LIABILITY

INSURANCE POLICY

Bariatric Surgery Supplemental Application
Basics
Applicant Name:
Date Applicant began Bariatric Procedures:
Number of Bariatric Procedures / Current Year / 1st year prior / 2nd year prior / 3rd year prior
In a Bariatric Center of Excellence:
Not in a Bariatric Center of Excellence:
Total Annual Bariatric Procedures:
Practice Information
Are you certified by the American Society for Bariatric Surgeons? / Yes No
Are you certified by the Society of American Gastrointestinal & Endoscopic Surgeons? / Yes No
Which of the following do you provide for your bariatric patients?
Nutrition Counseling / Respiratory Therapy
Mental Health / Other (describe):
Please provide the following about the bariatric patients your practice will accept:
Minimum Age: / Maximum Age:
Minimum BMI: / Other criteria (describe):
Procedures by Type
List the approximate number of procedures by type for your bariatric practice for this year and next year:
Type / Annual Procedures - Current Year / Annual Procedures – Projected
Open / Laparoscopic / Open / Laparoscopic
Adjustable Gastric Banding
Biliopancreatic Division
Duodenal Switch
Gastric Balloon
Gastric Sleeve Gastrectomy
Roux-en-Y Gastric Bypass
Vertical Banded Gastroplasty
Other:
Totals:
Has the above breakdown by type changed by 25% or more since your current retroactive date? If “Yes,” describe: / Yes No

I attest that the above information is true and complete to the best of my knowledge, that this information becomes a part of my application for coverage to AXIS, and that it is subject to the same conditions and warranty of my AXIS application.

Applicant’s Signature / Print Name & Title / Date

HPL-654 (05-14) Page 1 of 1