Patient Estimate Form
If you have insurance, please be sure to have a copy of your current insurance card before filling out this form.
Required Fields
INSURANCE INFORMATION
Do you have health insurance? Yes No                 Reset Form
FINANCIAL ASSISTANCE
Would you like to see if you are eligible for financial assistance? (Check box if yes)
Is your Gross Annual Income below, but not greater than?
(Combined income for you and your spouse)
How many people are in your household?
(Including yourself, spouse, and minor children)
Please complete the following fields
PRIMARY INSURANCE INFORMATION
Insurance Company:
Insurance Company Phone: - -
Name of Insured:
(First Name)

(Last Name)
Policy/Certificate #:
Group Number:
Employer:
Do you have a
secondary insurance?
(Check box if yes)
Please complete the following fields
SECONDARY INSURANCE INFORMATION
Insurance Company:
Insurance Company Phone: - -
Name of Insured:
(First Name)

(Last Name)
Policy/Certificate #:
Group Number:
Employer:
PATIENT INFORMATION
Date:4/25/2014
Patient Name:
(First Name)
 
  (Last Name)
Date of birth: / / Gender: Male Female
Phone: - -
(Home)
    - -
   (Work)
OK to leave message on patient's answering machine? Yes No
Street Address:
City:     State:     Zip:
Services will be
provided at:
Methodist Hospital
Jennie Edmundson Hospital
Methodist Physicians Clinic
Physician:
(First Name)

(Last Name)
(In order to give a more accurate estimate, we may call your physician to confirm your procedure.)
Description of procedure:
Approximate date for
service/procedure:
Click Here to choose date
Would you like an
email response?
Yes No Email Address:
Confirm Email:
By submitting this form, you give MHS permission to contact your physician/insurance company if we need more information to complete your estimate.
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