Cost Estimate Request
Riverview Health

Cost Estimate Request

To request a comprehensive, personalized cost estimate based on your insurance plan or self-payment, please complete this form, and one of our financial services team members will follow up with you.

How to Request a Cost Estimate

  1. Once you have seen your healthcare provider and discussed any upcoming procedures, ask your provider's office for the specific procedure code(s) of the medical procedure he or she recommends.
  2. Complete and submit the cost estimate form below.
  3. One of our financial services team members will review your request and respond within three business days to provide information about your estimate.

It’s important to note that the information we provide is only an estimate––services provided are customized to each patient’s specific needs.

For information about the cost of your specific care, please contact our patient financial services staff at 317.776.7141.

Cost of Care Estimate Request

It’s important to note that the information we provide is only an estimate––services provided are customized to each patient’s specific needs.

By submitting this form, I acknowledge that I am requesting a cost estimate for a procedure(s) at Riverview Health. I understand that the estimate will be based on the information I have provided and the most current benefits available from the insurance company. Additional charges will apply if other services are provided that are unknown at the time of this estimate. This estimate may not include all charges for incidental supplies or medications related to the services performed. In addition, this estimate does not include any durable medical equipment, physician, surgeon, anesthesiologist, pathologist or radiologist charges. Those fees are billed separately by their respective billing agents and are not included in this estimate.