Binding Price Estimate

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

Patient (hereinafter “Patient”): _______________________________________

Service/Product: Repair Detached Retina

The Patient used Healthcare Bluebook to find a Fair Price for the services he/she needs. According to Healthcare Bluebook, the Fair Price for consumers who pay healthcare providers at the time of service or product delivery is ____$3,011______. Price is for an outpatient procedure. Overnight stay is not included

The Provider agrees to provide Repair Detached Retina to the Patient for a total price of (please complete and check agreed upon price):

 $3,011  or
  _________, subject to the terms below:

1. Price is for an outpatient procedure. Overnight stay is not included

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


Patient Instructions:

Please take the Healthcare Bluebook binding estimate agreement to your healthcare provider. Share the Fair 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:

Healthcare Bluebook offers healthcare pricing as a free resource for patients in order to inform them of fair prices in their market. While Healthcare 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 patients paying at the time of service or product delivery. If you would like to learn more about Healthcare Bluebook or becoming a featured facility on Healthcare Bluebook, please visit us at www.healthcarebluebook.com.