Request for Price Quotation

and Out of Pocket Expense

Type or Print in Black Ink Pressing Firmly.

Part I

Patient Information

FULL NAME (First-Middle-Last-Suffix)

DATE OF QUOTE
MM
DD
YYYY

PATIENT I.D.

Indicate which insurance responsibility this quote is for:

Part II

Benefit Out of Pocket Items

PRIMARY

1. If benefits require a co-pay, please indicate the amount here:

SECONDARY

TERTIARY

How many times will it apply for a single visit?

The following is the total extended amount of co-pay cost that will be offset from insurance payment:

(1.)

2. Based on the benefits quoted, please indicate the remaining amount of deductible to be met:

(2.)

3. Please list the patient coinsurance percent applicable after co-pay(s) and deductible are met:

(3.)

4. Based on the benefits quoted, please indicate the remaining out of pocket amount to be met:

(4.)

5. If there is a policy benefit limit that will apply to the current visit, please list the available amount:

(5.)

0.00

Part III Service Item Pricing

In the space provided below, please list all service items to be performed during the visit. Include the quantity per item and the single unit price.
Code - Modality - Service Description
Fee Amount Units

Extended

0.00
0.00
0.00
0.00
0.00
0.00

1
2
3
4
5
6
TOTAL $

Part IV Out of Pocket Estimation

1a. Before insurance will pick up a portion of the cost, the patient has the following amount to meet:

(1a.)

1b. If the total from Part III is less than the amount on line 1a, report the Part III total amount here:

(1b.)

2a. After insurance picks up on cost share, based on cost share percent the patient will also owe:

(2a.)

2b. If the amount in 2a exceeds the amount in Part II line 4, report the Part II line 4 amount here:

(2b.)

3a. Based on available benefits quoted and calculated, this is the estimated insurance portion:

(3a.)

3b. If the amount in 3a exceeds the amount in Part II line 5, report the Part II line 5 amount here:

(3b.)

Based on the available plan information, the following is the estimated out of pocket expense:

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