Binding Price Estimate

Agreement
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Healthcare Provider / Facility (hereinafter “Provider”): ____________________________

Patient (hereinafter “Patient”): _______________________________________

Service/Product: Anesthesia for Cataract Surgery

According to the Healthcare Bluebook, the Fair Price for consumers who pay healthcare providers with cash at the time of service or product delivery is ____$398______. Price is for an average surgery time of 30 minutes. Prices may go up or down based upon the actual surgical time required.

The Provider agrees to provide anesthesia for Cataract Surgery to the Patient for a total price of (please complete and check agreed upon price):

 $398  or
  _________, subject to the terms below:

1. Price is for an average surgery time of 30 minutes. Prices may go up or down based upon the actual surgical time required

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.

________________________ ________________________
Patient Provider
________________________ ________________________
Date Date


Instructions:

Please take the Healthcare Bluebook binding estimate agreement to your healthcare provider. Share the Bluebook 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 Bluebook as a free resource to patients to inform them of fair healthcare prices. While the Bluebook 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 Bluebook or join the CareOperative Provider Network, please visit us at www.CAREOperative.com.

www.HealthcareBluebook.com www.CAREOperative.com