BayCare's My Estimator

BayCare now provides price estimates for a wide range of common medical services, including inpatient and outpatient procedures. Please complete the form below and a BayCare representative will review your information within two business days and contact you via your preferred method of communication. For assistance in completing the web form, please review Tips for Completing the Price Estimate Form. You may also call (813) 852-3116 for assistance during normal business hours.

Before You Start

Please gather the following information before completing this form:

Referring physician’s name and phone number
Procedure code (if known)
Insurance information (if you have insurance), including company, member ID/policy number, group number

Request for a BayCare Patient Cost Estimate

* Patient's First Name:

* Patient's Last Name:

* Street Address:

* City:

* State:

* Zip Code:

* Phone:

* E-Mail:

* Re-enter E-Mail:

* Birthdate:

Gender: MaleFemale

* How would you like to be contacted?: E-MailPhoneMail

* Referring Physician Name:

* Referring Physician Phone:

Procedure Code provided by Physician:

* Choose a Facility Type:

* Choose a Preferred Hospital Facility:

* Choose a Preferred Outpatient Imaging Center:

* Choose a Preferred Ambulatory Surgery Center:

* Description Of Procedure/Service:

* Are You Currently Scheduled for this Service? YesNo

* If "Yes" enter the date of the scheduled date of service:

* If "No" enter the date of the anticipated date of service:

Is this request for an inpatient or outpatient service?

* Do you have Health Insurance?: YesNo

* Health Insurance Company:

* Policy Holder's Name:

* Member/ID Policy #:

* Group Number:

* Health Insurance Company Phone:

* Do you have Secondary Insurance?: YesNo

* Terms and Conditions :

* Please note that estimates are not a guarantee of your total patient responsibility. The exact cost of a procedure may vary based on circumstances that may arise during the course of your treatment. Therefore, your benefit estimation can change as your medical circumstances change or as previous claims are received and processed by your insurance company (if you have insurance coverage). Estimates do not include any fees for physician services (radiologist, pathologist, anesthesiologist, surgeon, etc.), which may be billed separately.

I have read and I understand the Terms and Conditions above.