Patient Estimate Form

Patient Estimate Form

If you have insurance, please be sure to have a copy of your current insurance card before filling out this 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:	3/5/2015

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:

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.