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Insured Patients - Financial Out of Pocket Estimate Request Form

Baptist Health's Corporate Pricing Office is available Monday - Friday, 9 a.m. - 5:00 p.m. E-mails sent after hours or on the weekends will be returned within 48 hours or the next business day.

For help in receiving an estimated financial out of pocket quote, simply fill out the online form below.

By submitting this online request form, you agree to the Terms and Conditions of Use and the website Privacy Policy. If you do not agree to these terms, you may call Baptist Health Corporate Pricing Office at 786-662-7181 to request an estimated financial out of pocket quote.

Personal/Contact Information
First Name *
Last Name *
Patient First Name *
Patient Last Name *
Address *
Address 2
City *
State (if in United States)
Zip Code *
Country *
Telephone *
Fax
Date of Birth *  ...
Email Address
Medical/Procedure Information
A description of services is needed. We will need you to provide as much information as possible about the specific services described by your physician. For surgical estimated quotes, you may be asked to provide us with the specific CPT Procedure code which is a five-digit numerical procedure code and can be obtained from your physician. This code will help in determining the procedure being preformed and the estimated financial responsibility.
Physician/Specialist Name providing or ordering the services: *
Description of Services *
CPT Procedure Code(s)
Operating Room Length of Time (for surgical procedures only)
Date of Service  ...
Facility of Choice: *
Insurance Information
The CPO will also need information from your insurance card, so please have the card handy.
We will need the following information from your card.
Health Plan Name *
Type of Plan * Other
Policy Holder's Name *
Policy Number *
Group Name
Group Number
Health Plan's Phone Number
Policy Holder's Date of Birth *  ...
Policy Holder's Social Security Number
Yearly Deductible
Deductible Amount Met
Current Co-Payment Amounts (if applicable)
Coverage %
Other
(Co-insurance % policy holder is responsible to pay)
Yearly Maximum Out of Pocket
Yearly Out of Pocket met

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