Forms and Instructions for Weight Loss Surgery in West Palm Beach

Our forms section provides you with forms to download and complete before visiting our office. Completing these forms before your visit will save you time and ensure that you have all of the necessary documents available for our medical team to review.

  1. Financial Policy
    Jacksonville Weight Loss Financial Policy
  2. HIPAA notice
    Our privacy and HIPAA compliance policy
  3. Medical Release
    Authorization for release of medical records to other agencies
  4. Insurance Verification
    Notice of insurance verification for LAP-BAND surgery
  5. Patient Responsibility Form
    Jacksonville Surgical Associates Patient Responsibility Agreement
  6. Media Release Form
    Consent for taking and publishing photographs
  7. Program Fee Form
    Program fee refund policy
  8. Weight Loss Program Tax Deductions
    Internal Revenue Service policy (IRS Ruling 202-19)on deducting the cost of a weight-loss programs as a medical expense.
  9. 5-Year Weight History
    Five-Year Patient Weight History
To schedule a consultation, contact us today 561-627-4107