Request a Price Estimate - California
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Anonymous Login Code:
Code Entry Page
Save this code which is required to update your response at a later time.
Note: In the state of California, all CASH pay procedure estimate requests MUST come from the Provider's office on a pre-pricing form. If you do not have a form, please contact us
via email
.
1.
Name of requestor
*
2.
Name of patient (if different from requestor)
3.
Patient date of birth
*
4.
CPT code and/or Operating Room time/Bed Days.
The CPT procedure code (not a diagnosis code) is for the medical service or procedure that you want us to estimate. This code, which identifies a specific medical service, is available through your physician's office:*
*
5.
Email address:
6.
Phone number:
7.
How do you wish to be contacted?
*
Email
Phone
Okay to leave a detailed voice message at this phone number?
8.
Select your facility where service is to be performed:
*
-- Please Select --
Providence Medical Institute clinics
Providence Holy Cross Medical Center
Providence Little Company of Mary Del Amo Diagnostic Center
Providence Little Company of Mary Medical Center San Pedro
Providence Little Company of Mary Medical Center Torrance
Providence Saint John's Health Center
Providence Saint Joseph Medical Center
Providence Tarzana Medical Center
9.
Is your appointment/procedure scheduled in the next 24
hours/business day
?
Yes
No
10.
Is the patient insured
? (Please select yes even if insurance isn’t being used for this service.)
*
Yes
No
Name of the insurance company
Insurance ID number
11.
Is there any additional insurance coverage?
Yes
No
Name of the insurance company
Insurance ID number
12.
Comments:
Done