Healthcare Provider / Facility (hereinafter “Provider”): ____________________________
Patient (hereinafter “Patient”): _______________________________________
Service/Product: Elbow Surgery
According to the Healthcare Blue Book, the fair price for consumers who pay healthcare providers with cash at the time of service or product delivery is ____$4,332
______. Price is for a 2 day admission. More days charged at $1800 per day. Fewer days will reduce price by $1800 per day
The Provider agrees to provide Elbow Surgery
to the Patient for a total price of (please complete and check agreed upon price):
_________, subject to the terms below:
1. Price is for a 2 day admission. More days charged at $1800 per day. Fewer days will reduce price by $1800 per day
2. If the actual service or product required to treat the patient is different from that listed above, then Provider will make a reasonable effort to inform Patient what the new service or product is and what the price will be before treatment.
3. Other terms or conditions: __________________________________________
Patient agrees to pay Provider in full at the time of service or in the manner that is agreed to in advance and acceptable to Provider.
In consideration of above, the parties indicate their agreement by signing below.
Please take the Healthcare Blue Book binding estimate agreement to your healthcare provider. Share the Blue Book price with your provider and ask them to provide a cost estimate to you. Once you have agreed on an acceptable price, you can complete the above agreement for your records.
Notice to Healthcare Providers:
CareOperative offers the HealthCare Blue Book as a free resource to patients to inform them of fair healthcare prices. While the Blue Book prices are generally below “billed charges”, they are also generally above standard insurance contract rates accepted by most providers. The prices should be fair compensation for cash paying patients. If you would like to learn more about the Healthcare Blue Book or join the CareOperative Provider Network, please visit us at www.CAREOperative.com