Refer a patient to the Weight Loss Surgery Program
If you are a MaineHealth provider, please enter referrals through EPIC AMB REF1104. If you do not have access to EPIC, please mail or fax the following information.
- Referral for the evaluation and treatment of morbid obesity (ICD-9 278.01)
- Referral authorization # from the insurance company
- BMI (or most recent height and weight)
- All related diagnoses and comorbidities
- Previous attempts/duration of unsuccessful weight loss
- Demographic Information on the patient (DOB, address, phone number, insurance info)
- Most recent H&P including blood work and medications
Smokers will be required to quit smoking and have a nicotine level drawn and sent to us before their first appointment.
MMC Weight and Wellness Program
41 Donald B. Dean Drive Suite A
South Portland, ME 04106