Out-of-Pocket Expense Information


By providing us with the information requested below, we will be able to estimate your out-of-pocket responsibility for your upcoming test or procedure.

Once you have submitted your information, you will receive an estimate within 2 business days.

If you have any questions or if you would like a MSHA representative to assist you in completing this form, please call our Pre-Visit Coordination Team at (423) 431-1776 between the hours 8:00 am to 5:00 pm Monday through Friday.

Estimates are currently only available for the facilities listed below.
 
 
 

Procedure:

 
 
 
 
 
 
 
 

Address (optional)

To ensure that we prepare your quote as accurate as possible, we may need to contact you for clarification on your insurance or procedure information. In this event, what is the best time to contact you at the phone number given?
 

Definitions:


Insurance Copay Amount : The amount you must pay out of pocket at the time of your medical visit. This information will be indicated on your insurance card.

Co-Insurance Percentage: The portion of the insurance allowable amount that you are responsible for (ex. 90%/10% or 80%/20%). This information will be indicated on your insurance card.

Annual Deductible Amount: The amount you are required to pay per year before your insurance coverage begins. This information will be indicated on your insurance card.