EHC Cost Estimate Request


Patient Pricing Estimate Request
Thank you for selecting Emory Healthcare as your choice for your healthcare needs. Please complete the following form and click the 'Complete Entry' button at the bottom of the page. In order to process this request, you will be required to verify that the information provided is complete and accurate. A confirmation of receipt will appear once the form has been submitted.
Please note that the asterisk * Indicates required Information
First Name * Last Name *
 
Email Address *
 
Home Phone * Other Phone
 
Best time to be reached
 
Do you or the patient have an upcoming appointment with Emory Healthcare? *
Location
Procedure Name or Description
 
CPT Code (from your physician)
If unknown, please type "unknown"
for the CPT Code.
 
Performing Provider to provide service/procedure for which you are requesting an estimate
 
Referring Physician
Referring Physician Phone
 
Are you the patient?
Do you have health insurance? *
Name of Insurance Company
 
Insurance Company Phone
 
Name on Insurance Card
 
Relationship of the patient to the policy holder
 
Insured Patient's Date of Birth
(mm/dd/yyyy)
 
Policy Number
 
Group Number
Please include any additional information that you feel may help us with this request.
 
*  By checking this box, I acknowledge that I am requesting a cost estimate for a procedure(s) at Emory Healthcare. I understand that the estimate will be based on the information I have provided herein. I confirm that, to my knowledge, this information is complete and accurate.

I understand the estimate provided is not a guarantee of coverage and that, depending on my individual case, I may be held liable for other charges that are medically necessary as a part of my care or are not directly related to the services requested in this form.

 
Unless otherwise noted, we will follow up with you via phone call to provide your estimate. If you prefer, we are glad to communicate your estimate via email. Please keep in mind that the information transmitted to you in the estimate is protected health information and is covered by the Health Insurance Portability and Accountability Act (HIPAA). Emory Healthcare is not able to protect information sent via email and will not be held liable for any information transmitted via email. All information provided is at risk for being read by a third party, such as your email service provider (i.e. Google, Yahoo, Hotmail, etc.).

* If you would like to receive your estimate information by email, please click "YES" below. If you would prefer the standard phone call, please click "NO".
 I have read and understand the risks associated with sending my information via email and would like to receive estimate and pricing information via email.
 I do not want my information transmitted via email. Please follow up with me via phone call.

 
Click the Complete Entry button when you entered all required fields.