Patient Registration

Patient Registration Weight Loss

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VIVE Concierge Health / Patient Registration


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Marital Status:

How did you hear about VIVE Concierge Health?

If so, who?

Emergency Contact

Insurance Information

Medical insurance policies do not typically cover weight management care and related expenses, including laboratory testing, electrocardiograms, prescription medication and related  your primary diagnosis is obesity, you may not bill your insurance company for a coどmorbid condition. Doing so may result in a charge of fraud against you and/or the physician.

An appropriate receipt of payment will be provided, including a charges and descriptions of the office visit for the different levels of service provided. The codes used for this purpose may or may correspond to the codes used by insurance companies.

Changes to “codes” will not be made for the use of any insurance company. Insurance companies may reimburse patients for expenses related to weight management, for instance if comorbid conditions are also part of the weight management treatment, but reimbursement will not be made from the insurance company to the physician. Again, please understand that will not present a bill to any supplements. If insurance company for weight management services or related charges. Also, VIVE Concierge Health will provide what is considered an appropriate receipt, as above described and is not obligated to complete any form that may be provided by a health insurance company sent to the patient or physician in this regard and sign an informed waiver prior to participation in this Weight Management Program.

Medicare Beneficiary

Are you currently a beneficiary of Medicare?

Supplement Key Chain Pill Fob

We may provide a supplement key chain pill container as part of a new patient starter kit or as separately sold item. This container is not approved or appropriate for storing controlled substances, such as prescribed medications. All prescribed medications must remain in their originally labeled bottle.

Patient Statement of Understanding

I have read and fully understand the above information related to insurance and participation in VIVE Concierge Health weight loss program. I have also had the opportunity to ask questions regarding these issues. I am aware that I will receive an appropriate receipt of payment for my personal use as I see fit to do so. I understand the specifics of these receipts and limitations as described in this document. I accept these specific policy rules.
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