Healthcare Imaging Quote

HEALTHCARE IMAGING QUOTE

Imaging Provider:   Address:

Quote Number:   Date Issued:   Prepared By:

Patient Information

Date of Birth:   Gender:   Phone:

Emergency Contact:   Phone:

Referring Provider

Referring Physician:   Office/Facility:

Referring Phone:   Contact Person:

Insurance Information

Policy / ID #:   Group #:   Subscriber Name:

Coverage Type: Private Insurance Medicare Medicaid Self-Pay

Medical History (Brief)

Requested Imaging Services (Estimated)

Itemized Services

CPT / Code:   Description:   Qty:   Unit Fee:   Est. Total:

CPT / Code:   Description:   Qty:   Unit Fee:   Est. Total:

CPT / Code:   Description:   Qty:   Unit Fee:   Est. Total:

Estimated Charges Summary

Subtotal:   Estimated Insurance Payment:   Estimated Patient Responsibility:

Prior Authorization Required: Yes No   Estimated Preauthorization Submitted:

Terms, Disclosures, and Patient Responsibility

This document is an estimated cost statement prepared for scheduling and financial planning purposes only. It is not authorization to perform imaging services. Final billing will reflect actual services performed, coding adjustments, insurer adjudication, and any applicable facility or professional fees.

Estimated amounts are based on information available at the time of issuance. The patient remains responsible for any deductibles, copayments, coinsurance, non-covered services, prior balance, and charges resulting from changes in the procedure, additional imaging sequences, or findings that require further study.

If insurance coverage is denied or payment is not received from the insurer, the patient or guarantor agrees to accept responsibility for payment. The imaging provider may seek preauthorization or submit claims on behalf of the patient; however, preauthorization does not guarantee payment.

Cancellation and No-Show Policy: Scheduled procedures canceled with less than 24 hours' notice or unattended appointments may be subject to a cancellation fee. Fees will be assessed in accordance with facility policy and are the patient's responsibility.

Collection and Legal Fees: Unpaid balances may be referred for collection. The patient or guarantor agrees to pay reasonable collection costs and attorneys' fees, if applicable, as permitted by law.

By signing below, the patient acknowledges receipt of this estimate, understands that it is not a final bill, and consents to the imaging provider performing scheduling and insurance verification activities necessary to facilitate the imaging services. The patient further acknowledges the obligation to pay any amounts determined to be the patient responsibility.

Authorization Expiration Date:

Acknowledgment & HIPAA (Limited)

I acknowledge that I have received a copy of the imaging provider's privacy practices and authorize the release of medical information necessary for treatment, payment, and healthcare operations related to the imaging services described in this estimate.

Relationship to Patient (if signed by guardian or responsible party):

Sign Now