Please know that email communications via our website may not be done through a secure platform. Although it is unlikely, there is a possibility that information you include in your submission may be intercepted and read by parties other than the intended recipient. In order to provide you with the requested Good Faith Estimate, we will need certain personal identifiable information and/or protected health information including your name and date of birth. To protect your confidential information, please do not include any personal identifiable information and/or protected health information beyond what is requested in the form. By submitting the request and information, you are accepting the risks and possible personal or financial harm which may occur as a result of your submission via our website. In the event you would prefer to request your Good Faith Estimate in another manner, please contact us at 844-468-9498.
Patients First name*
Patients Last name*
Requestor First name*
Requestor Last name*
Requestors relationship to the patient*
Patients Date of birth*
Services to be self-pay or insured?* self-payinsurance
If insured, please share insurance carrier’s name*
Street Address*
City*
State*
ZIP Code*
United States
Patients contact preference* —Please choose an option—By mailBy encrypted emailBy unencrypted emailBy phone
Supply the encrypted email*
Supply the unencrypted email*
Supply the telephone number*
Who’s telephone number is listed?*
Primary diagnosis CPT*
Length of surgery*
Date of treatment
Location of treatment* Select LocationAscension Via Christi St. FrancisAscension Via Christi St. TeresaKansas Surgery and Recovery Center
Surgeon’s full name*
