Estimate of Medical Fees

Instructions for: Estimate of Medical Fees

This “Estimate of Medical Fees” could be part of your practice Informed Financial Consent Policy. Its purpose is to clearly identify non-covered or elective services, typically at the beginning of treatment.

Be aware of individual third-party payer policies regarding the notification of these types of services. Some payers have their own specific forms that must be used. For example, CMS has their own form called the Advanced Beneficiary Notice (ABN) which must be used to inform Medicare beneficiaries of the patient’s financial responsibility when services may be denied/non-covered.

This form is for those cases in which there is no third-party payer requirement. It helps the patient understand the financial implications before treatment begins.

Download Forms:

• Estimate of Medical Fees