Online Request for Bariatric Surgery Coverge

You must answer all questions for your information to be submitted for medical review. If you are unable to answer all of the questions, you may quit and return when you have all of the required information.

Subscriber ID: (located on the front of your UMP ID Card. The "W" at the beginning of the number must be capitalized.) Your date of birth:  (mm/dd/yyyy)     What is your age in years?     About how tall are you without shoes? - 2 feet 3 feet 4 feet 5 feet 6 feet 7 feet and - no inches 1 inch 2 inches 3 inches 4 inches 5 inches 6 inches 7 inches 8 inches 9 inches 10 inches 11 inches About how much do you weigh without shoes, in pounds?     What is your gender? Male Female Have you been diagnosed with diabetes? Yes No What was your most recent hemoglobin A1C?     Have you been diagnosed with high blood pressure? Yes No Have you been diagnosed with sleep apnea? Yes No Have you been diagnosed with heart disease? Yes No Have you been diagnosed with high cholesterol or high lipids? Yes No What medications are you currently taking? (Maximum of 4000 characters.) What is your daytime phone number? Click here to return to the UMP Main page