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Estimated Hospital Costs
Cost Estimate Request

Prospective patients in the Texas Health Resources family of hospitals are welcome to request a cost estimate for any hospital procedure. Estimates are based on hospital charges for anticipated routine care and recovery, taking into consideration insurance coverage, co-payments, deductibles, coinsurance and other information that may affect personal out-of-pocket costs.

To get answers, simply complete and submit the form below. A Texas Health representative will review your information and contact you within two business days to provide details. Or you may call 1-877-PRE-ADMT (1-877-773-2368) for immediate assistance during business hours.

* Indicates required information
First Name * 
Last Name * 
Street Address * 
City * 
State * 
Zip * 
e-mail Address * 
Home Phone * 
Other Phone 
Preferred Texas Health Hospital * 
Procedure Name or Description * 
CPT or ICD-9 Code (get from Dr.) * 
Do You Have Health Insurance * 
If yes, please provide the info below: 
Name of Insurance Company 
Insurance Company Phone No. 
Insured Name on Ins. Card 
Insured Patient's Birth Date (MM/DD/YYY) 
Policy Number 
Group Number 
The info below, if known, will help us refine your estimate: 
Co-insurance Percentage 
Co-pay $ Amount 
Deductible $ Amount 
Deductible $ Amount Met 
Max. Out-of-Pocket $ Amount 
Out-of-Pocket $ Amount Met: 
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