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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.

Fax: 207-253-6073

MMC Weight and Wellness Program
41 Donald B. Dean Drive Suite A
South Portland, ME 04106

Phone: 207-661-6064