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Coffeyville Regional Medical Center

Procedure or Treatment Pricing Request

Thank you for allowing us the opportunity to serve you. If you would like an estimated (may be higher or lower than the actual cost) cost of a procedure or treatment, please complete the following information and we will reply back to you within two business days. For additional information, or questions, please call our scheduling department at 620-252-1523 during the hours of 8:30 a.m. to 5:00 p.m., Monday through Friday.
Once you have submitted this form you will receive an email, or telephone call, from us within two business days. Again, thank you for allowing us to assist you and choosing Coffeyville Medical Regional Center for your healthcare needs.
This transmission is the property of Coffeyville Regional Medical Center, Inc. and is confidential, intended solely for the use of the organization to whom it is addressed. If you are not one of the named recipients or otherwise have reason to believe that you have received this message in error, please notify the sender at 620.252.1530 and delete this message immediately from your computer. Any other use, retention, dissemination, forwarding, printing, or copying of this transmission is strictly prohibited.
* Name
First and Last name please.
  Email Address
* Telephone Number
* Mailing Address
* City/State/Zip
Example: Coffeyville, KS 67337
* Name of Physician
* Name of Procedure or Treatment
* Anticitpated date of procedure or treatment
  May we contact your physician o receive coding information for the procedure or treatment?
  Name of Insurance Company
If you would like to know your estimated financial responsibility for this service, please complete the insurance information:
  Policy Number
  Group Number
  Subscriber's Name
  Insurance company's Telephone Number
  Patients Date of Birth
  If you have addtional insurance, please enter it here:
  We have payment options available to assist you with your financial responsibility. Would you like to receive a call from one of our Financial Advisors?