Form for Co-Providers to Request a Good Faith Estimate from CentraCare
Facility Name
*
Name of healthcare facility where procedure or service will occur
Facility Type
*
Hospital
Outpatient Clinic
Other
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
*
First Name
Last Name
Contact Person Email
*
example@example.com
Contact Person Phone Number
*
-
Area Code
Phone Number
Preferred Method of Response
Email
Fax
Contact Person Fax Number
-
Area Code
Phone Number
National Provider Identifier
*
Taxpayer Identification Number
*
Patient Information
Patient Name
*
First Name Middle Name Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Insurance Type and Identification Number
*
If patient is uninsured, enter 'no insurance'
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
*
-
Area Code
Phone Number
Patient Email
example@example.com
Primary Procedure or Service For Price Estimate
*
Patient Primary Diagnosis
*
Primary Diagnosis Code
*
Patient Secondary Diagnosis
Secondary Diagnosis Code
Name of CentraCare Physician or Provider
*
Provider performing procedure or service
Procedure or Service
*
Is Scheduled
Is NOT Scheduled
Date of Scheduled Procedure or Service
-
Month
-
Day
Year
Submit
Should be Empty: