Name First Name Last Name Date of Birth Phone Email Preferred Contact Phone Email Procedure code (CPT) or description of service Note: Current Procedural Terminology (CPT) is a medical code set that is used to report medical services to physicians and health insurance companies. Preferred location for procedure Do you have insurance?* Yes No Do you have any financial assistance? Yes No All requests may take up to 3 business days. The more accurate the information provided above, the faster the request will be completed. Please note that all professional billing (i.e. billing for surgeons, radiologists, physicians, and anesthesiologists) will be done separately and are not included in the estimates unless stated otherwise. This estimate is based on our current pricing and is subject to change. While we make every effort to ensure the accuracy of our estimates, it is impossible to predict final out of pocket costs due to the many variables within the actual services that are not determined until the day of care. Therefore, please note the estimate provided is not a guarantee of cost for this service. Additional costs may be involved if the physician chooses to do a different set of testing, additional procedures, or requests consults from other providers on the case. Confirm * - I have acknowledged the above disclaimer statement. Comment / message: Message to the Patient Estimates Team member preparing your estimate Hospital Request* CPH GH
