Price Estimate Request Form | Baylor Scott & White Health

A Baylor Scott & White Health price estimate representative can assist in providing estimated out-of-pocket costs for your care with us. Use this form to send us an email with your information and a representative will respond within two (2) business days with your estimate.

Patient Information

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Patient's Phone Number (xxx-xxx-xxxx)

Date of Service

Location of Service

Physician/Specialist Name (if known)

Do you have health insurance? Yes No

Description of Service or Procedure or Current Procedure Terminology (CPT) Code

Inpatient or Outpatient

Account Number (if known)

Additional Information or Comments

Requestor Information (if not patient)

Requestor's First Name

Requestor's Last Name

Requestor's Phone Number (xxx-xxx-xxxx)

Today's Date

By selecting "submit request" you confirm that you understand the following statements.

Any information received is only an estimate. The estimated price will be based on information you and your provider share with us about what services are expected to be performed. Many factors will influence the actual amount you will be billed, including whether the provider finds it necessary to perform more, fewer or different procedures than originally expected at the time of service.

Any information received reflects only hospital charges. It does not include charges for services provided by the physician, surgeon, radiologist, anesthesiologist, emergency room physician or other providers.

If you are insured, prior to your visit, it is important that you contact your insurance company to ensure that the services required are "covered services." In the event that they are not a covered service under your plan, please refer back to our uninsured information.

¹Current Procedural Terminology (CPT) Code - A CPT code communicates to payers what medical and surgical procedures and diagnostic services are rendered by your provider and where payment is expected. You can find this on the on the order from your doctor.