Request for Non-Scheduled Services

OSUWMC is committed to helping patients address their financial concerns and questions. Please complete the form below providing as much detail as possible to request a price estimate. Once your request is submitted, you will receive a response from our office within 3-5 business days.

Request an estimate for scheduled services here

Disclaimer

This is a good faith estimate only. This estimate does not indicate that the services or procedures have been preauthorized, pre-certified or predetermined by your insurance company. Actual amounts owed for the services provided may depend on your specific care needs at the time of service. This includes treatments or services considered necessary by your health care provider during the visit and additional information provided by your insurance.

The final out-of-pocket costs you may owe depends on many factors such as:

• The service or procedure location
• Insurance company and plan. Not all insurance companies and plans are in network with OSUWMC
• Anesthesia services
• Other services or procedures that your provider determined were needed for you
• The amount and type of medicines or infusions ordered and given in clinic
• Services that have frequency limitations
• Additional professional provider fees could include but are not limited to pathology, anesthesiology, attending physician, admitting physician and surgeon

This estimate does not include any benefit coverage from secondary insurance. The final cost to you will be determined by your insurance company when your claim is processed for payment.