Patient Estimate Form | SimpleCare Health Plan

	Patient Estimate Form

If you are a SimpleCare member, please be sure your membership is in force before filling out this form.

PATIENT INFORMATION
Date: *
Patient Name: *	(First Name)	(Last Name)
Date of Birth *
Phone: *	(Home)	(Work)
OK to leave message on patient’s answering machine?*	Yes No
Address *
Town *
Postcode *
Province *
Services will be provided at:*
Physician: *	(First Name)	(Last Name)
(In order to give a more accurate estimate, we may call your physician to confirm your procedure.)
Description of procedure: *
Approximate date for service/procedure:: *
Would you like an email response?	Yes No	Email Address: Confirm Email:
By submitting this form, you give SimpleCare permission to contact your physician/hospital if we need more information to complete your estimate.