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Request a Cost Estimate

Request a Cost Estimate

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Request a Cost Estimate
Pay Your Bill Online

To receive an estimate for a specific procedure at a WellSpan facility, please complete and submit the form below.

If you are a WellSpan employee, or dependent, enrolled in the WellSpan Plus insurance plan, please contact WellSpan Population Health at 717-851-6800 to inquire about estimates.

Patient Name:

Date of Birth:

Insurance Name or Self Pay:

Insurance ID#:

Email:

Phone Number:

May we leave a message on your answering machine?
Yes
No

What is the preferred location for your procedure?
Apple Hill Surgical Center
Day Surgery - WellSpan Ephrata Community Hospital
WellSpan Ephrata Community Hospital
WellSpan Gettysburg Hospital
WellSpan Good Samaritan Hospital
WellSpan Physician Office
WellSpan Surgery & Rehabilitation Hospital
WellSpan Surgical Center - Gettysburg
WellSpan Surgical Center - Lebanon
WellSpan York Hospital
Other WellSpan Facility
Not sure

If other facility, or not sure, please provide the facility and/or county where you will be having the procedure?

Will this be an inpatient or outpatient procedure?
Outpatient
Inpatient
Not sure

CPT Code: (This can be provided by your physician office)

Description of the procedure:

ICD-10 Diagnosis Code:
(This can be provided by your physician office)

Additional information that may be important in determining our estimate:

If you need assistance, please contact our cost estimate line at 1(833)-4MY-COST.

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