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Call Dr. Rutledge 702-714-0011 or Email: DrR@clos.net |
Call Dr. Peraglie 407-922-3424 or Email: DrP@clos.net |
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Tips for Completing the Patient Information Form· Very Important: Before you start: Print out a copy of the blank form and read it carefully. · Very Important: Collect all of the needed information (insurance information, medication spelling and doses, doctor's address phone and fax etc.) prior to filling out the form. · Very Important: Fill out the paper form before filling out the form online. · Very Important: If you are new to the Internet get help filling out this form. · Very Important: Make sure that you have just signed on to the Internet before you start filling out the form. · Very Important: After you have sent the form make sure that you get a confirmation page. · Very Important: Print out the confirmation page and then use the back button on your browser and print out two copies of the form, one to keep and one to take with you to clinic.
Letter to Your Insurance CompanyIt is important for you to understand that the patient information that you submit on the Internet will be used to create a letter to your insurance company. This letter will be sent to you as an email attachment in Microsoft Word 2000 format. If you are planning to try to obtain insurance approval then it will be up to you to print out and send this letter to your insurance company to begin the “prior-approval or pre-determination” process with your company. This process varies from company to company and from policy to policy. Under no circumstances can Dr. Rutledge or his office be part of this effort. This is your responsibility. Reminder: Dr. Rutledge No Longer Accepts InsuranceAs we stated above, Dr. Rutledge does not accept insurance. After you submit the patient information form the information that you have submitted will be used to write a letter that can be sent to your insurance company. The letter uses the information that you send in your patient information form to generate a letter about your level of obesity and the associated levels of disability and other medical illnesses. Patients can use this letter in their efforts to obtain support from their healthcare insurers to cover their obesity surgery. But, remember that Dr. Rutledge does not accept insurance or any kind of third-party billing as payment for services. We will not under any circumstances submit claims to insurance carriers. We do not accept payments on time or any form of payment plans. We only accept money orders, credit cards or certified checks. Dr. Rutledge does not accept insurance assignment and does not represent or warrant any availability of insurance reimbursement for any particular claim. The letter that our office will send you is for the private use of you and your primary care physician. It should not in any way be considered an indication that Dr. Rutledge will participate in your insurance plan’s payment network or contracts. Again it needs to be emphasized that the charges you incur for the Mini-Bypass must be paid before your surgery. Dr. Rutledge does not accept insurance reimbursement and the letter does not mean that he will be willing to involved with any insurance company contracts. Receipts for your surgery are provided to you. We can provide our patients with the billing information they need to try to obtain reimbursement from your insurance company. You can submit Dr. Rutledge’s bill to your insurance company. If you choose to file an insurance claim on your own, please be aware that any issue dealing with the insurance companies will have to be handled by you, your family or your lawyers. Dr. Rutledge and his office do not have any working relationship with any medical insurance providers. Our office can only provide minimal assistance to patients in processing claims to their insurance carrier. If you are reimbursed for the surgery, that will be between you and your insurance company. Getting Insurance ReimbursementYour insurance policy is an agreement between you and
your insurance company. In contrast, an agreement on services and fees is an
agreement between you and your surgeon. When you have surgery with Dr.
Rutledge, you become responsible for payment of the doctor's fees. Coverage
for services and levels of payment by your insurance company depend on the
terms of the contract between you and your insurance company. Reading your own policyIt's important to understand what's included in your
policy before you advance too far in planning surgery. Some policies provide
coverage for different types of obesity surgery procedures while others are
more limited in coverage. Read your policy and benefits manual carefully and
discuss any questions you may have with your insurance plan manager. Your Patient Intake PacketCheck List:Print out the checklist to help you keep track of where you are in the process. Before you send in your packet, use the checklist again to confirm that all your information/requirements are included in your packet.
Patient Intake Packet: Format and Submission RequirementsMake a Duplicate Copy of Everything in the PacketMake a copy of your packet before you send it. How to Send in your ApplicationWe recommend you send it via FedEx or Priority Mail. Contact their representatives to find out if it’s been delivered and if you are due a refund. General Advice on How to Format Your PacketSubmit your packet loose in a single letter-size folder. Staple the items together that are multiple pages. Put colored and labeled tabs on each requirement on the long right hand side of the section. DO NOT put each page in plastic sheets. DO NOT send in the packet in a bound notebook, or in a 3-ringed notebook. Every part of the packet should be neatly typed and readable Packet ContentsTell Us Who You Are (4 pages typed)Four page typed letter with one page on each of the following topics describing 1. Who you are 2. Your background 3. Why you want to have this surgery 4. Ability to pay for the surgery Show Us You are a Candidate for Surgery (1 page typed)One to two page typed letter addressing each of the criteria for surgery and how you meet each of the criteria for surgery Show that You Have Completed Your Preoperative Education (3 pages typed):One page each showing that you have: 1. Downloaded and read the patient manual 2. Spent time reading the web site 3. Joined the mailing list Give examples of some things that you have learned from each of these sources of preoperative education. Preoperative Multidisciplinary AssessmentSupport from your Local Physician:A variety of early, medium and long-term complications, problems and illnesses can cause difficulties after the operation. Dr. Rutledge is committed to provide long-term follow up for all of his patients after Laparoscopic Gastric Bypass. But, since many patients are from hundreds and even thousands of miles away, it is imperative that patients develop a close relationship with a local medical physician who has the interest and the knowledge to follow patients with Dr. Rutledge and care for them through out the years after surgery. An interested and committed local physician is also critically important in providing additional assistance in the preoperative evaluation of patients prior to surgery. In addition, our experience has demonstrated that patients are often difficult to contact after operation. In several cases it was a contact with a local physician that allowed us to find our patient and determine how they are doing. This is crucially important given the long-term risks of the gastric bypass as it relates to vitamin and mineral deficiencies. For all of these reasons we require the following process in the preoperative assessment and preparation of patients for Laparoscopic Gastric Bypass: The patient must obtain a letter from his or her local medical physician. The letter must include 1.) An assessment of your obesity and its impact on you health and quality of life, 2.) A detailed thorough and meticulous assessment by your Dr. of your medical, surgical and psychological fitness for surgery, and 3.) Your Dr's willingness to follow you after surgery. All patients are required to have a close working relationship of at least several months with a local physician. The physician must support the patient’s desire to proceed with Mini-Bypass. The physician must perform a thorough detailed complete history and physical evaluation as a preoperative screening step prior to considering patient for Laparoscopic Gastric Bypass. This should be included in your packet and be typed usually a minimum of two pages in length. Scribbled unreadable faxes and check box forms are not acceptable. The patient must obtain a letter of support and the medical records from their physician and the preoperative history and physical examination for review prior to proceeding with surgery. Letter from Dr. Rutledge to Your Doctor Explaining the Process:Explaining expected recovery and follow up benchmarks and complications (i.e. depression …)
Request for letter: I. Assessing the patient’s obesity and its impact on his or her health and quality of life II. Assessing patient’s medical, surgical and psychological fitness to undergo major abdominal surgery III. Stating your willingness to follow patient in concert with me over the long term especially for monitoring for vitamin and mineral deficiencies Dear Dr., Your patient has contacted me in reference to being considered for a laparoscopic Mini-Gastric Bypass. Request for a Letter of Support: I would like to request a letter from you about your patient. I request a letter from the primary medical physician of all of the patients that I consider for laparoscopic Mini-Gastric Bypass to assist me in the evaluation of the patient’s obesity and their candidacy for surgery, to promote the patient’s further consideration of the risks and benefits of surgery and to improve the quality of the post operative care of the patient by requiring the patient to have a documented relationship with a health care provider. For the patient to be considered for operation the patient must provide me with a letter from his/her physician that includes a detailed assessment of the patient’s obesity and its impact on his or her health and quality of life. I ask for an assessment of the patient’s medical, surgical and psychological fitness to undergo major abdominal surgery (essentially a history and physical examination). Finally I request that the patient’s physician state his or her willingness to follow the patient in concert with me over the long term. This is especially important for encouraging the patient to remain in contact with healthcare providers to continue his or her multivitamin regimen (3 standard multivitamin tablets per day) and for yearly monitoring for vitamin and mineral levels to identify and treat potential deficiencies. I ask that you consider providing this letter directly to the patient. It must be included as part of the very extensive application package I require for the patient to create in preparation for surgery. In addition to your letter the patient must provide us with copies of his or her pertinent past medical records, a complete history and physical with the results of a recent CBC, Electrolytes and EKG, a letter of support and understanding of the risks and benefits of surgery from the patient’s family, full length front and side photographs, contact with at minimum 10 of my previous patients who have undergone this surgery and a 10 page letter written by the patient demonstrating knowledge of: 1. Understanding the Risks of Obesity 2. Understanding Morbid \ Clinically Severe Obesity 3. Understanding Why the Operation is performed 4. Understanding How the Operation is performed 5. Understanding the Expected Benefits of Surgery 6. Understanding the Expected Risks of Surgery 7. Understanding the Risks of Gastritis, Ulcers and Bile Reflux 8. Understanding what to take for Pain and Colds 9. Understanding of the Alternatives to Surgery 10. Understanding the Post Operative Diet Changes 11. Understanding the Risks of Alcohol, Acetaminophen and Liver Disease 12. Understanding the Possible Depression After Operation 13. Understanding When to Use the Estrogen Patch in Women 14. Understanding the Need for Long Term Follow Up 15. Understanding the H. Pylori, the Billroth II and the risks of stomach ulcers, gastritis and stomach Cancer All of this information is to be put together into a package that is presented to me to be reviewed prior to operation. I have as of performed over 1,287 laparoscopic Mini-Gastric Bypasses. Over the three years that I have been performing this surgery we have had 1 hospital death. The operative procedure takes an average of 45 minutes in previously unoperated patients and the hospital stay is 1 day in over 90% of patients. The mean weight loss is 140 lbs at one year and we have has greater than 90% success in reversing diabetes, sleep apnea, hypertension etc. We have operated upon patients from 42 states across the U.S. including Alaska and Florida, as well as Puerto Rico and Iceland. For any further information please check our web site at http://clos.net or call our office at (919) 479-4400. Your help in the preoperative evaluation of this patient is greatly appreciated.
Robert Rutledge, M.D., F.A.C.S.
2. Other Medical/Health problemsIf you have other Medical or Health problems you will need to see each of those specialists for their assessment and advice about how your medical and health issues might affect your candidacy for surgery, your risk of surgery and your long term results of surgery. Please ask each of your medical specialists to send Dr. Rutledge a detailed letter describing your special medical or health issues that that particular Doctor is taking care of you for, ask him or her to comment upon how this illness might affect your candidacy for the surgery, your risk of surgery and how it might affect your long-term results after the surgery. Does he/she approve or recommend the surgery in your case? Does he/she support your having the surgery? Please ask that your specialist advise Dr. Rutledge of any special precautions, pre/post-op recommendations for your care. This might include special use of medications or additional consultations or tests.
Psychiatric/Psychological Evaluation:All our patients are now requested to undergo a psychiatric evaluation to assess their psychological status prior Gastric Bypass. It is a requirement for a patient to see a psychologist or psychiatrist in preparation for the surgery. The National Institutes of Health Consensus Conferences states that a psychiatric evaluation in preparation for surgery is recommended. There are certain contra-indications psychologically for weight loss surgery. An evaluation by your usual medical doctor will not fulfill these criteria. Either a psychologist or a psychiatrist can perform it. A social worker or other therapist is not an acceptable choice a social worker or other therapist is not an acceptable choice A social worker or other therapist is not an acceptable choice The patient should have a routine psychiatric evaluation to rule out significant eating disorders or other major psychiatric illnesses that may affect the results of surgery. Patients with inadequately treated depression need to be appropriately diagnosed and treated prior to surgery. Alcohol and drug abuse are also relative contraindications to surgery. The patient must not have unrealistic expectations of the outcome of surgery. Guideline For Psychiatric Evaluation Purpose of Evaluation The psychiatric evaluation includes a face-to-face interview with the patient. A general evaluation usually takes no more than 1 hour to complete. Several meetings with the patient should not be necessary. The psychiatric consultation is requested for the purpose of assisting in the diagnosis, treatment, or management of a patient's possible mental disorder or behavioral problem. This evaluation should be comprehensive. The aim of the consultative psychiatric evaluation is to provide clear and specific answers to the questions including: · Patient's competency in deciding to proceed with gastric bypass. Is the patient competent to decide to proceed with surgery? · History of Substance Use. Does the patient have a past history of drug or alcohol use, abuse or dependence? If so what role might this play in the future of this patient given the expected stress that occurs in the postoperative period? · The presence of any Psychiatric diagnosis relevant to the gastric bypass; in particular is the patient psychotic? If any form of psychiatric illness is identified then prognosis and treatment advice should be included. · Willingness of the psychologist/psychiatrist to follow and treat the patient in the postoperative period. In addition the letter should include a commitment to be available for consultation in the event that depression occurs in the postoperative period. · Patient's ability to handle the stress of the period that follows surgery The evaluation should respect the patient's relationship with the primary clinician and should encourage positive resolution of conflicts between the patient and the primary clinician if these emerge as an issue. Issues to be Addressed in the Psychiatric Evaluation: History of the Present Illness, Past Psychiatric History, General Medical History, History of Substance Use, Social History, Occupational History, Family History, Review of Systems, Mental Status Examination, Functional Assessment, Information Derived From the Interview Process. Depression ScaleInstructions: You might reproduce this scale and use it on a weekly basis to track your moods. It also might be used to show your doctor how your symptoms have changed from one visit to the next. Changes of five or more points are significant. This scale is not designed to make a diagnosis of depression or take the place of a professional diagnosis. If you suspect that you are depressed, please consult with a mental health professional as soon as possible.
The items below refer to how you have felt and behaved DURING THE PAST WEEK. For each item, indicate the extent to which it is true, by circling one of the numbers that follows it. Using the following scale: 0=Not at all 1=Just a little 2=Somewhat 3=Moderately 4=Quite a lot 5=Very much ===========================================================
Postoperative Multidisciplinary Follow up PlanFollow up with Dr. RutledgeReturn to Clinic 1 week, 1 month, 3 months, 6 months 1 year and then yearly for everComplete follow up form
Follow up with your local medical DoctorReturn visit 1 month, 3 months, 6 months 1 year and then yearly for everComplete follow up form and submit it to Dr. RutledgeYour Medical Records:We need copies of you past medical records to evaluate as part of our preoperative assessment. (Note: We only need important medical records, no cuts and bruises or runny noses.) Pap smears, routine mammograms and other screening tests are up to your medical Doctor’s discretion. Dr. Rutledge no longer requires them for the surgery. Patient Contacts:To meet this requirement you have to contact at least 10 previous patients as part of your application package. You must also fill out the online patient contacts form. It is located on the Internet at: http://clos.net/forms/ patient_contacts_form.htm
For each of your patient contacts please type the patient's first and last name, the method of contact, the patient's email address, the patient's date of operation, the patient's preoperative weight, the patient's weight now, the date of contact and 1-2 paragraphs of written information about the contact demonstrating that the contact was made. Ask questions such as:
Get the list of volunteer post op patients from Dr. Rutledge. When you have contacted all of your 10 patients, fill out the ONLINE PATIENT CONTACTS FORM. Print a copy before you submit it. Submit it online. You should include a printed copy of this online form in your packet.
Patient Letter (15 pages typed):One of the most important efforts of the preoperative preparation of patients for the Laparoscopic Gastric Bypass is an education about the risks and benefits of the operation. When we surveyed patients about our efforts to educate them about Laparoscopic Gastric Bypass surgery, we received a high level of approval. Over 90% of patients said that the risks and benefits of operation had been explained to them. Despite this high rating, our goal is to insure that every patient fully understands the benefits and consequences of this serious surgery. To try to improve our success at educating patients about the operation we are now requiring patients to write a letter showing that they understand the risks and benefits of Laparoscopic Gastric Bypass. It's extremely important that you understand the surgery before you undergo it... as well as your alternatives. If you have to rethink the surgery, its potential complication and its alternatives once or twice... that's not so bad, as the surgery you are undertaking is life changing and potentially life threatening (as is any surgery). Sure, you've thought about it a million times in your mind, but writing it out... that takes a bit more thought. My advice as to writing... pretend you are talking to your best friend... assume s/he is asking you the questions... make your letter your answer to your friend. The letter requirement is based upon educational research showing that retention of information is improved by asking the learner to think about and write down the information. Patients who are not able to understand enough to write a letter detailing the risks and benefits of the operation will be poor candidates for Laparoscopic Gastric Bypass. Required Patient Letter Contents: The patient is asked to write a typed letter addressing each of the fifteen topics. The patient is asked to write one typed page on each topic. Hand written letters are not acceptable. The typeface to be used 12 point and the line should be 1 to 1 and ½ space on each page. 5. Understanding the Risks of Obesity 6. Understanding Morbid \ Clinically Severe Obesity 7. Understanding Why the Operation is performed 8. Understanding How the Operation is performed 9. Understanding the Expected Benefits of Surgery 10. Understanding the Expected Risks of Surgery 11. Understanding the Risks of Gastritis, Ulcers and Bile Reflux 12. Understanding what to take for Pain and Colds 13. Understanding of the Alternatives to Surgery 14. Understanding the Post Operative Diet Changes 15. Understanding the Risks of Alcohol, Acetaminophen and Liver Disease 16. Understanding the Possible Depression After Operation 17. Understanding When to Use the Estrogen Patch in Women 18. Understanding the Need for Long Term Follow Up 19. Understanding the H. Pylori, the Billroth II and the risks of stomach ulcers, gastritis and stomach Cancer
Family Letter:One of the factors that has been identified from our patient survey is the importance of the family in successfully coping with the stresses that occur in the postoperative period. Patients that live alone and / or are far from their family members appear to have more problems than those with close supportive families. Because of these findings, we are changing our methods for preoperative evaluation as well as the processing of patients prior to consideration for surgery. Some of our main goals include an assessment of the patient’s family structure and education of family members about the patient’s interest in the gastric bypass. This will require that the spouse, parent, brother, sister or adult children accompany the patient to at least one (ideally all) of the clinic visits. This changes our past policy and is designed to improve the quality of care provided to our patients. The family must also be able to learn about and understand the educational issues related to the laparoscopic gastric bypass. Patients must provide a detailed description of their family and family support structure. Family member(s) must accompany the patient to the educational preoperative visits. Family members must have an equal understanding of the issues related to selection of the Laparoscopic Gastric Bypass. The Patient will choose a family support member to write their letter. If the patient is married the spouse must submit a family letter. It must also be signed and notarized when submitted in the packet. Photographs:As part of our documentation effort patients will be required to provide descriptive front and side full body and facial photographs to allow us to have another method to grade the success of the procedure. The photograph should be taken in light solid colored clothing, usually tan in front of a solid colored wall. After operation the patients are asked to provide roughly similar photographs at 6 months and one year and on a yearly basis for the ensuing five years following operation. On the back of the photographs should be the patient’s name, present address, contact telephone number and body weight at the time of the photograph. Remember: Your Photos Must come with their name and address on the back of each photo.
Clinic Visit with Dr. RutledgeBefore coming to clinic it is suggested that have completed your history and physical examination with your Doctor. Clinics are on Tuesday and Thursday at 1 pm. You have to pre-register between 9-11 am. at the office. Directions are on the web site at the back of the Patient Education Manual. When you pre-register, you will be weighed & your waist measured. You will be given some forms to fill out and bring to clinic in the afternoon, and a map to the clinic location. You will need to arrange your own transportation. Clinic is 4-6 hours so you may need to make work or child care arrangements for that day. Please wear two-piece outfits at both Clinics so that Dr. Rutledge can easily examine your abdomen prior to surgery and post-op for easier removal of staples. You will return to the Post-operative Clinic the following week for your staple removal and final checkup. Come to the Clinic location for 1 pm. You will also have an opportunity to ask questions of Dr. Rutledge or his Staff. Packet Submission:Requirements · Very Important: Make a copy of your packet before you send it. We cannot readily return or copy your packet. · $100 is charged for Packet Review using a credit card ONLINE. A receipt will print out and a copy will need to be included in your packet. This does not guarantee that you will be a suitable candidate for surgery. · Please consider sending your application package via FedEx or Priority Mail. You can contact their representatives to find out if it’s been delivered and if you are due a refund. · Submit your packet unbound in a single, letter-size manila folder. · Staple the sections together that are multiple pages, i.e. your patient letter. · Put labeled tabs on each requirement on the long right hand side of the item. · IMPORTANT: DO NOT put each page in plastic sheets, in a bound notebook, or in a 3-ringed notebook. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Disclaimer Notice:-Information on this web
site is provided for informational purposes only. |
