Patient Estimate

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Please select an option below.

This option provides an estimated cost for hospital services that include insurance reimbursement and the estimated patient portion. Patient identifiable information will be required to determine benefits and eligibility.

This option will locate a prior payment estimate. A previous estimate number is required.

This option provides an estimated cost for hospital services and insurance reimbursement. Patient identifiable information is not required.

Visit Information

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Please complete the information below.
(*) indicates a required field.

FACILITY*

VISIT TYPE*

PROCEDURE CATEGORY*

Make a selection to see a list of associated tests and procedures

PROCEDURE(S):

+ add another procedure

What type of procedure would you like to estimate?

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Insurance Information

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Please complete the information below. (*) indicates a required field.

ARE YOU INSURED*

YES

INSURANCE NAME*

MEMBER ID / POLICY NUMBER*

GROUP NUMBER

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PATIENT'S RELATIONSHIP TO THE POLICY HOLDER*

SELF

SPOUSE

CHILD

OTHER

POLICY HOLDER'S FIRST NAME*

POLICY HOLDER'S LAST NAME*

POLICY HOLDER'S DATE OF BIRTH*

GENDER*

FEMALE

MALE

Payment Estimate

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The following is an estimate of charges based upon the information you provided. Please save your reference number for future access.

PATIENT NAME:UNKNOWN Estimate prepared on:UNKNOWN EST. #:N/A Diagnosis Code:Not Provided Patient Group:Not Provided Service:Not Provided

Facility:UNKNOWN UNKNOWN NPI #:UNKNOWN Tax ID:UNKNOWN

INSURANCE COVERAGE

Insurance Name

N/A

Remaining Deductible

N/A

Out-of-Pocket Remaining

N/A

Copay

N/A

Co-Insurance % / Max

N/A / N/A

HOSPITAL SERVICE CHARGES

Procedures:

Total Estimated Gross Charge

$0.00

Total Contracted Discount

$0.00

Payer-Specific Negotiated Charge

$0.00

Total Insurance Portion

$0.00

Total Estimated Patient Portion

$0.00

PATIENT PORTION BREAKDOWN

View Detailed Breakdown

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Thank You!

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Note: Estimate accuracy may be impacted by values entered in this screen.