Complete the Estimate Request Form below to receive a personalized cost estimate within two business days.
This good faith estimate is based on the most current coverage and benefit information provided by your insurance company (if you have insurance coverage), and the typical care experience for patients receiving similar services from your physician. We would like to caution you that this is not a guarantee of the final amount due. Hospital care is specifically tailored to the needs of each patient. Therefore, the final amount owed may vary based on circumstances involved in your actual services. Such circumstances may include:

• The length of time spent in surgery or recovery
• Specific equipment, supplies and medications required
• Additional tests required by your physician
• Any special care, unexpected conditions or complications
• A change in your insurance benefits

Please note that the good faith estimate provided by Faith Multispecialty Hospital covers hospital services only; it does not include professional fees for services provided by independent practitioners, such as your primary care physician, surgeon, radiologist, pathologist, anesthesiologist, emergency room physician, or other specialist. These providers bill separately from the hospital, and you may contact them directly for pricing information.

Patient Name *
Birth Date*
Gender *	Select Gender Male Female
Doctor's Name*
Do you know the CPT Procedure Code(s)?*	--Select-- Yes No
CPT Procedure Code
Description of Procedure
Do you know the ICD-9 Diagnosis Code?*	--Select-- Yes No
ICD-9 Diagnosis Code
Description of ICD-9 Diagnosis Code
Do you have health insurance?*	--Select-- Yes No
Health Insurance Company Name*
Health Insurance Member ID
Health Insurance Company Phone Number
Does your service(s) require an overnight stay at the hospital?*	--Select-- Yes No
Type of Response Requested* (How may we contact you ?)
Email Address
Telephone Number