Financial Estimate

First Name

Last Name

Do you have insurance coverage?

YesNo

Insurance Company Name

Group/Plan

Individual Member Number

Are you the guarantor (insurance owner) or is that someone else?

YesNo

First and last name of guarantor/insurance owner

What is your primary phone number where we may reach you?

Example: 555-555-5555

What is your date of birth?

Example: 01/01/2001

Is your procedure scheduled?

YesNo

What is the date of your procedure?

Example: 01/01/2001

Have you been given a specific TEST code or PROCEDURE (CPT) code for your visit?

YesNo

Please enter your TEST code or PROCEDURE (CPT) code or a description of the service you are hoping to schedule.

What is the name of the facility where you will have your procedure?

Do you have any other information we should know about your upcoming procedure?

What regional area should your submission be directed to?

This will help ensure your questions are routed to the team best equipped to answer - select the region you received care in, or the region that is closest to you.

I verify that all of the information in this estimate request is accurate and correct.

I AGREE

Disclaimer Language:

Your UnityPoint Health estimate covers hospital charges only. Patients may receive a separate bill from other healthcare providers such as anesthesiologists, radiologists or pathologists who have a separate contract to provide certain services within the hospital. While we make every effort to ensure the accuracy of your estimate, the actual charges on your final hospital bill may vary from it due to unknown circumstances, complications, final diagnoses and treatments ordered by the attending physician(s).

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