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  Use the "Estimate Request Form" option to obtain an estimate of charges and out of pocket expenses:

Before you come to Geisinger you can know the approximate amount your services will cost, what your insurance is expected to pay and how much you might owe after insurance. Complete the form below to obtain an estimate of charges and out of pocket expenses. You will need your insurance card, type of procedure you are considering and the Geisinger Hospital Name where the procedure will be preformed. The written or verbal estimate will be sent/provided within two (2) business days.
Date: 11/21/2009
Patient Name:
Medical Record Number:
Birth Date (mm/dd/yyyy):
Gender: male   female
Daytime Phone Number (999-999-9999):
Street Address:
City:
State:
Zip Code:
Services to be performed at:
Department:
Procedure:
Description of Procedure (if Other selected above):
Type of Insurance:
Blue Cross Geisinger Health Plan
Health America Highmark
Medicare Self Pay
Other
Subscriber ID (please include prefix):
Relationship to Subscriber: self   spouse   child   other adult
Subscriber Name:
Subscriber Gender: male   female
Subscriber Birth Date (mm/dd/yyyy):
Member ID:
Subscriber ID:
Subscriber Name:
Subscriber Birth Date (mm/dd/yyyy):
Subscriber Group ID:
Subscriber SSN (999-99-9999 if Group ID not known):
Subscriber ID (please include prefix):
Subscriber Name:
Subscriber Birth Date (mm/dd/yyyy):
Medicare ID:
Insurance Company Name:
Insurance Street Address:
Insurance City:
Insurance State:
Insurance Zip Code:
Subscriber Name:
Relationship to Subscriber: self   spouse   child   other adult
Insurance Member # / Agreement #:
Subscriber SSN (999-99-9999 if Group ID not known):
Type of Response (how may we contact you?): Telephone Call (no messages please)
Telephone Call (messages ok)
US Mail
By submitting this form you give Geisinger Health System permission to contact your insurance company to confirm eligibility and for benefit information.