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Estimate My Cost® enables you to create your own accurate out-of-pocket price estimates anytime, anywhere.
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Disclaimer
Please review prior to proceeding.
The hospital’s charge for the above services are approximate charges for these services based on information provided at time of estimation and DO NOT include charges associated with physician services for which you will be billed separately. The final amount of the hospital’s charge may be different from that shown above due to additional tests or procedures performed/ordered by the physician(s) or medical technicians, or due to complications that may arise during the course of treatment. Therefore, the total amount for which you will be responsible may be higher or lower than that stated above.
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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*
Your preferred location of healthcare service.
VISIT TYPE*
The patient's type of healthcare service based upon the kind of care needed.
    PROCEDURE CATEGORY*
    Make a selection to see a list of associated tests and procedures
    The broad category or department classification that the procedure or test may be listed under.
      PROCEDURE(S):
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          Patient Information
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          Please complete the information below. (*) indicates a required field.
          FIRST NAME*
          The first name of the patient.
          LAST NAME*
          The last name of the patient.
          DATE OF BIRTH*
          GENDER*
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          Insurance Information
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          Please complete the information below. (*) indicates a required field.
          ARE YOU INSURED*
          INSURANCE NAME*
          The policy holder's health insurance plan as listed with the healthcare facility.
          MEMBER ID / POLICY NUMBER*
          The member or policy identification number found on the card issued by the health insurance plan.
          GROUP NUMBER
          The group number found on the card issued by the health insurance plan. This group number identifies the specific benefits associated with the patient's employer's health insurance plan. Not all health insurance plans have a group number.
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          PATIENT'S RELATIONSHIP TO THE POLICY HOLDER*
          POLICY HOLDER'S FIRST NAME*
          POLICY HOLDER'S LAST NAME*
          POLICY HOLDER'S DATE OF BIRTH*
          GENDER*
          Coverage
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          To edit your coverage amounts select the amount or pencil icon.

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

          COPAY
          Edit Copay A fixed amount (for example, $15) you pay each time for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service.
          DEDUCTIBLE
          Edit Deductible The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've paid $1,000 annually for covered services. Some plans pay for certain health care services before you've met your deductible.
          CO-INSURANCE
          Edit Co-Insurance Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance after you've met your deductible. For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your 20% coinsurance payment would be $20. The health insurance plan pays the rest.
          CO-INSURANCE MAX
          Edit Co-Insurance Max The maximum amount of coinsurance a patient can be required to pay.
          OUT-OF-POCKET MAXIMUM
          Edit Out-Of-Pocket Maximum The most you'll have to pay for covered services in a policy period (usually one year). After you reach this amount, your health plan will pay 100% for covered essential health benefits.
          OUT-OF-POCKET REMAINING
          Edit Out-Of-Pocket Remaining The amount remaining towards reaching your maximum out-of-pocket amount.
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          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
          The policy holder's health insurance plan as listed with the healthcare facility. Insurance Name
          N/A
          The amount remaining that you will have to pay annually for your healthcare before the health insurance pays anything. Remaining Deductible
          $-.00
          The amount remaining towards reaching your maximum out-of-pocket amount. Out-of-Pocket Remaining
          $-.00
          A fixed amount (for example, $15) you pay each time for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service. Copay
          $-.00
          The percentage of costs of a covered health care service you pay after you've paid your deductible and the total amount of coinsurance that you will owe of covered expenses for a calendar year. Co-Insurance % / Max
          --  /  N/A
          HOSPITAL SERVICE CHARGES
          The listing of procedures to be performed. Procedures:
          The estimated charge for an individual item or service that is reflected on a hospital's chargemaster, absent any discounts. Total Estimated Gross Charge
          $-.00
          The amount a health care provider writes off or adjusts from a patient's balance in accordance with agreement with the health insurance plan covering that patient. Total Contracted Discount
          $-.00
          The charge that a hospital has negotiated with a third party payer for an item or service. Or if self pay, the discounted cash price that applies to an individual who pays cash, or cash equivalent, for a hospital item or service. Payer-Specific Negotiated Charge
          $-.00
          The amount your health insurance plan will pay your health care provider. Total Insurance Portion
          $-.00
          Total Estimated Patient Portion
          $-.00
          PATIENT PORTION BREAKDOWN
          View Detailed Breakdown
          Your primary insurance provider, or self, who pays your healthcare provider directly for medical expenses. Coverage Level
          N/A
          A fixed amount (for example, $15) you pay each time for a covered health care service, usually when you get the service. The amount can vary by the type of covered health care service. Copay
          $-.00
          The amount you owe for covered health care services before your health insurance plan begins to pay. For example, if your deductible is $1,000, your plan won't pay anything until you've paid $1,000 for covered services. Some plans pay for certain health care services before you've met your deductible. Deductible
          $-.00
          Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You pay coinsurance after you've met your deductible. For example, if the health insurance plan's allowed amount for an office visit is $100 and you've met your deductible, your 20% coinsurance payment would be $20. The health insurance plan pays the rest. Co-Insurance
          N/A
          The amount remaining towards reaching your maximum out-of-pocket amount. Out-of-Pocket Excess
          N/A
          Total Patient Coverage Portion
          $-.00
          PRICE TRANSPARENCY ELEMENTS
          View Price Transparency Elements
          The charge for an indivdual item or service that is reflected on a hospital’s chargemasteer, absent any discounts. Gross Charge
          $-.00
          The charge that applies to an individual who pays cash, or cash equivalent, for a hospital item or service. Discounted Cash Price
          $-.00
          The lowest charge that a hospital has negotiated with all third party payers for an item or service. De-identified Minimum Negotiated Amount
          $-.00
          The highest charge that a hospital has negotiated with all third party payers for an item or service. De-identified Maximum Negotiated Amount
          $-.00
          The charge that a hospital has negotiated with a third party payer for an item or service. Payer-specific Negotiated Charge
          $-.00
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          My Estimates
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          View previously created Estimates
          FIRST NAME
          LAST NAME
          DATE OF BIRTH*
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