Cost Estimate Request

You can request a good faith estimate to help identify potential out-of-pocket costs, such as copays, deductibles, coinsurance, or expenses not covered by your insurance plan.

Anyone with or without insurance may request an estimate. You can even request an estimate if you do not have an appointment. If you have an appointment scheduled, please submit the request at least three days before your appointment.

If you have questions about completing the form or prefer to provide your details via phone, please call 570-322-8448 and ask to speak with the medical billing specialist.