At Carle, we are committed to helping you make informed choices about your care. That includes helping you know, in advance, an estimate of the amount you owe after your insurance pays, or if you do not have or provide insurance, how much you will be charged for services and goods.
Carle provides estimates for a wide range of common medical services by determining an average service bundle from the historical billing of the service. This estimate is a good-faith attempt to let you know your portion of the cost for the service selected. The resulting estimate may not match your final bill exactly. Your final bill will depend on actual services, drugs, supplies and procedures performed as determined by your doctors.
Please keep in mind that there may be separate charges from the hospital services, such as Carle Medical Supply, Arrow Ambulance, Home Infusion
and other services depending on the individual situation that will not be included in this estimate.
you have the opportunity to shop for medical services, it is best to contact
your insurance carrier to understand which services and goods will be covered
and which will be your responsibility. They are most knowledgeable about the specific benefit plan, coverages and out of pocket responsibilities that your plan provides.
Hospital charges are the amount a hospital bills for a
service. Because of varying reimbursements from insurers, patients most often
pay far less than the amount listed.
If you believe the estimated amount due may create a financial hardship, you may be eligible for the Carle Financial Assistance Program that may offset some or all of your costs. To learn more about this program, click here.
Please gather the following information before completing this form:
Providing your insurance information will enable us to provide an estimate of the amount you will owe after your insurance pays. If you choose not to provide this information, we will provide you with the estimated total gross charges using an average service bundle from the historical billing of the service, and you will need to apply your plan's out of pocket amounts (e.g. deductible, co-insurance, non-covered, etc.) to calculate your estimated out of pocket costs. Because these calculations by insurers are typically based on the amount the insurer pays, and is NOT based on the hospital's billed gross charges, we recommend you contact your insurer for an estimate if you do not want to provide your insurance information to Carle.
The amount shown in an estimate is based on the information you provide. This estimate cannot and should not be relied on as the actual charges and/or payments you will be responsible for paying, and is in no way a quote, guarantee or contract for the amount that you may owe. You will be responsible for the actual amount you owe for services rendered.
Tips for Completing the Price Estimate Form
Patient First and Last Name
Please enter the name of the patient as it appears on the insurance card.
The best phone number to reach you.
Patient birthdate is needed to access insurance benefits.
Referring Physician Name
The physician who ordered your test or procedure. Enter the First and Last Name of your physician. For Surgical procedures please enter the Surgeon's first and last name.
Referring Physician Phone Number
Physician office number
Procedure Code provided by Physician
Five digit CPT code assigned to the procedure or test. Enter code if available.
Preferred Facility Type
Facility type where procedure will be performed.
Description of Procedure/Service
Ask your provider to clearly print the name of the procedure(s). Correct spelling is important as many surgery names sound familiar. If you have more than one procedure please separate them by a comma.
Anticipated date of service
If anticipated date is unknown enter approximate date (mm/yyyy).
Health Insurance Company
Please enter the insurance company name as it appears on the patient’s insurance card (for example Aetna PPO).
Policy Holder’s Name
The policy holder's name as it appears on the patient’s insurance card.
Member ID/Policy #
Please enter the Member ID/Policy # or subscriber # as it appears on the patient’s insurance card. This can be a combination of numbers and/or letters.
Please enter the Group Number or Plan Name/Description as it appears on the patient’s insurance card. This can be a combination of numbers and/or letters.
Health Insurance Company Phone
Please enter the customer service or provider phone number that appears on your insurance card.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan will not pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A provider who does not have a contract with your health insurer or plan to provide services to you. You will pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans do not count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
Beginning January 1, 2021, the U.S. Department of Health & Human Services and the Centers for Medicare & Medicaid Services requires hospitals and health systems to post their "current, standard charges." You can download and view these files here: