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
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?
35,735
47,915
60,095
72,275
84,455
96,635
108,815
120,995
(Combined income for you and your spouse)
How many people are in your household?
1
2
3
4
5
6
7
8
(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:
1/18/2021
Patient Name:
(First Name)
(Last Name)
Date of birth:
01
02
03
04
05
06
07
08
09
10
11
12
/
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
Gender:
Male
Female
Phone:
-
-
(Home)
-
-
(Work)
OK to leave message on patient's answering machine?
Yes
No
Street Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Services will be
provided at:
Methodist Fremont Health
Methodist Hospital
Methodist Jennie Edmundson Hospital
Methodist Physicians Clinic
Methodist Women's Hospital
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:
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.