Price Estimate Request Form

To help us provide you with the most accurate price estimate, please fill out all the required fields. It may be helpful to first contact your physician's office for services/procedures information. If you have insurance, please have your insurance card handy. If you have any questions, please call the Pricing Support Center at 844-786-9503 (toll-free) or 317-355-9279.

A patient may at any time ask a healthcare provider for an estimate of the amount the patient will be charged by the provider and health facility for non-emergency medical services provided in Community facilities. The law requires that the estimate be provided within 5 business days.

Personal/Contact Information

First Name:*

Last Name:*

Patient First Name:*

Patient Last Name:*

Phone Number:*

Date of Birth:*

Email Address

Medical/Procedure Information

Please provide as much information as possible about the specific medical services described by your physician. For surgical price estimates, you may be asked to provide us with the specific CPT Procedure code, a five-digit numerical procedure code that can be obtained from your physician. This code will help determine the procedure being performed and the estimated financial responsibility.

Physician/Specialist Name Providing or Ordering the Service:*

Description of Services:*

CPT Procedure Codes (if known):

Type of Procedure/Stay?*

Inpatient

Outpatient

Not Sure

Date of Service (if known):

Insurance Information

If you do not have insurance, you may skip this part. Uncheck the box and press Submit. If you do have insurance, please fill out the insurance information, usually found on your insurance card.

I Have Insurance

Insurance Details

Health Plan Name:*

Type of Health Plan:

Policy Holder's Name:*

Policy Holder's Date of Birth:*

Policy Number:*

Group Name:

Group Number:

Health Plan's Phone Number:

Coinsurance Percentage:

Annual Deductible:

Deductible Amount Met:

Disclaimer

The price estimate we will provide is based on the most common or average charge amount. However, because of unexpected circumstances or additional services, this is an estimate and cannot be guaranteed as a final bill. As healthcare can be complex, please be aware that you will be billed from Community Health Network along with other entities that are involved in your care but are not part of our Network. The estimate we will provide includes, but is not limited to, charges such as room and board, medication and supplies, OR time, pre-op and post-op care as well as professional services rendered by Community Health Network providers. For those services not billed by the Community Health Network, which can include professional fees, anesthesiologist fees and radiologist reading fees, we have worked in conjunction with these entities to obtain their estimated gross charge amounts. Finally, our estimate, specific to the services billed by Community Health Network, will include your estimated total out-of-pocket amount based on your current insurance benefits provided to us by your insurance carrier coverage and assumes your services are in-network.

Please press Submit only one time. Thank you!