PROCEDURE OR TREATMENT PRICING REQUEST

Thank you for allowing us the opportunity to serve you. If you would like an estimated (may be higher or lower than the actual cost) cost of a procedure or treatment, please complete the following information and we will reply back to you within two business days. For additional information, or questions, please call our scheduling department at 620-252-1523 during the hours of 8:30 a.m. to 5:00 p.m., Monday through Friday.

Name:
E-Mail Address:
Telephone Number:
Mailing Address:
City/State/Zip:
Name of Physician:
Name of procedure or treatment:
Anticipated date of procedure or treatment:
May we contact your physician to receive coding information for the procedure or treatment? 
If you would like to know your estimated financial responsibility for this service, please complete the following information:
Name of Insurance Company:
Policy Number and Group Number:
Subscriber's Name:
Insurance Company's Telephone Number:
Patient's Date of Birth:
Do you have a second insurance:
We have payment options available to assist you with your financial responsibility.  Would you like to receive a call from one of our Financial Advisors?

Once you have submitted this form you will receive an email, or telephone call, from us within two business days. Again, thank you for allowing us to assist you and choosing Coffeyville Medical Regional Center for your healthcare needs.

This transmission is the property of Coffeyville Regional Medical Center, Inc. and is confidential, intended solely for the use of the organization to whom it is addressed. If you are not one of the named recipients or otherwise have reason to believe that you have received this message in error, please notify the sender at 620.252.1530 and delete this message immediately from your computer. Any other use, retention, dissemination, forwarding, printing, or copying of this transmission is strictly prohibited.