Patient Price Estimation Request Form

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Patient Name
Address 2
Phone Number
Alternate Phone Number
Fax Number
How would you like to receive your written estimate?
Do you want us to call you with a verbal estimate in addition to sending a letter?
Physician's Name (if available)
Description of Procedure
CPT or Procedure Codes (if available)
Procedure Type
Payment Type
Insurance Plan (if applicable)
Security Code
Type Security Code

The required information must be provided in order for us to prepare an estimate. We will send a letter in response to this request within two business days of receipt. The estimate that will be provided is a range of possible prices or an average price, depending on your situation, for the facility only, and will not include physician or other professional provider fees that will be billed separately. The estimate will be based on the information provided above, may not be specific to any one BJC provider, and will not be specific to any particular insurance plan (if applicable).

If you have insurance, you should contact your health plan to make sure that the BJC hospital you would like to use is a provider in your plan’s network and to obtain information related to your specific benefit plan (such as whether or not the service is a covered benefit and the amount of deductible, co-payment or coinsurance you may owe.)

The actual price of the service may be more or less than the estimate provided and may vary depending on chronic health issues, medications, unexpected complications, and other factors. The estimate will not be a guarantee of what you may eventually owe.

BJC provides price information only on more common procedures, so an estimate may not be available for the procedure you are requesting. If an estimate is not available for the particular procedure for which you are requesting price information, someone will call you within one business day of receipt of your request to let you know that an estimate is not available.

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