Tips for Completing the Price Estimate Form
Patient First and Last Name:
Please enter the name of the patient as it appears on the insurance card.
What is the best phone number to reach you?
Patient birthdate is needed to access insurance benefits.
Referring Physician Name:
The physician who ordered your test or procedure. Enter the First and Last Name of your physician. For Surgical procedures please enter the Surgeon's first and last name.
Referring Physician Phone Number:
Physician office number.
Procedure Code provided by Physician:
Five digit CPT code assigned to the procedure or test. Enter code if available.
Preferred Facility Type:
Facility type where procedure will be performed
Description of Procedure/Service:
Ask your Doctor to clearly print the name of the procedure(s). Correct spelling is important as many surgery names sound familiar. If you have more than one procedure please separate them by a comma.
Anticipated date of service:
If anticipated date is unknown enter approximate date (mm/yyyy).
Health Insurance Company:
Please enter the insurance company name as it appears on the patient’s insurance card (for example Aetna PPO).
Policy Holder’s Name:
The policy holder's name as it appears on the patient’s insurance card.
Member ID/Policy #:
Please enter the Member ID/Policy # or subscriber # as it appears on the patient’s insurance card. This can be a combination of numbers and/or letters.
Please enter the Group Number or Plan Name/Description as it appears on the patient’s insurance card. This can be a combination of numbers and/or letters.
Health Insurance Company Phone:
Please enter the customer service or provider phone number that appears on your insurance card.