Financial Estimate

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First Name * Last Name *

Do you have insurance coverage? * Yes No

If you answered yes above, please provide your Insurance Company Name, Group/Plan Number and your Individual Member Number * Insurance Company Name * Group/Plan * Individual Member Number *

Are you the guarantor (insurance owner) or is that someone else? Yes No

If you answered no above, please provide the name of the guarantor/insurance owner First Name Last Name What is your primary phone number (where we may reach you)? Ex. xxx-xxx-xxxx * What is your date of birth? Ex. xx/xx/xxxx *

Is your procedure scheduled? * Yes No

If you answered yes above, what is the date of the procedure? Ex. xx/xx/xxxx *

Have you been given a specific TEST code or PROCEDURE (CPT) code for your visit? * Yes No

If you answered yes above, please enter your TEST code or PROCEDURE (CPT) code or a description of the service you are hoping to schedule. * What is the name of the facility where you will have your procedure? * Do you have any other information we should know about your upcoming procedure? I verify that all of the information in this estimate request is accurate and correct *

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Disclaimer Language:

Your UnityPoint Health estimate covers hospital charges only. Patients may receive a separate bill from other healthcare providers such as anesthesiologists, radiologists or pathologists who have a separate contract to provide certain services within the hospital. While we make every effort to ensure the accuracy of your estimate, the actual charges on your final hospital bill may vary from it due to unknown circumstances, complications, final diagnoses and treatments ordered by the attending physician(s).

UnityPoint Clinic - Express (Ankeny)

UnityPoint Clinic - Express (Jordan Creek)

UnityPoint Clinic - Express (Waukee)

UnityPoint Clinic Behavioral Health Urgent Care - Des Moines

UnityPoint Clinic Urgent Care - Altoona

UnityPoint Clinic Urgent Care - Ankeny Medical Park

UnityPoint Clinic Urgent Care - Ingersoll

UnityPoint Clinic Urgent Care - Merle Hay

UnityPoint Clinic Urgent Care - Southglen

UnityPoint Clinic Urgent Care - Urbandale

Financial Estimate

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The way we make people feel matters more than anything else.

Are you a current patient or new patient at UnityPoint Health?

UnityPoint Clinic - Express (Ankeny)

UnityPoint Clinic - Express (Jordan Creek)

UnityPoint Clinic - Express (Waukee)

UnityPoint Clinic Behavioral Health Urgent Care - Des Moines

UnityPoint Clinic Urgent Care - Altoona

UnityPoint Clinic Urgent Care - Ankeny Medical Park

UnityPoint Clinic Urgent Care - Ingersoll

UnityPoint Clinic Urgent Care - Merle Hay

UnityPoint Clinic Urgent Care - Southglen

UnityPoint Clinic Urgent Care - Urbandale

Financial Estimate

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