Get the free Hospital Statement of Cost BHF Page 1 Healthcare and - illinois

Hospital Statement of Cost BHF Page 1 Healthcare and Family Services, Bureau of Health Finance, 201 S. Grand Ave. E., Springfield, IL 62763 General Information Preliminary Name of Hospital: Union

How to fill out hospital statement of cost

How to fill out a hospital statement of cost:

1. Obtain the hospital statement of cost form from the hospital's billing department. They should provide you with the necessary paperwork upon request.
2. Start by filling in your personal information accurately. This information may include your full name, address, contact number, and date of birth. Be sure to provide the same information that is associated with your medical records to avoid any confusion.
3. Next, provide your insurance information. This may include your insurance provider's name, policy number, and group number. This is crucial as it helps the hospital bill your insurance company accurately.
4. If you are seeking reimbursement from a secondary insurance provider, make sure to include their information as well. This could include their name, policy number, and group number if applicable.
5. Indicate the specific period for which the statement of cost is applicable. This allows the hospital to accurately bill you for the services rendered during a specific timeframe.
6. Include the dates of service for each visit or procedure. It's important to provide the exact dates as it ensures that your bill aligns with the services you received.
7. Itemize the services you received during each visit or procedure. This typically includes details such as the name of the service, the CPT (current procedural terminology) code, and the charge for each service.
8. If you have any additional insurance information or documentation that needs to be submitted alongside the statement of cost, make sure to include it in the designated section or attach it separately.

Who needs a hospital statement of cost:

1. Patients who wish to review and understand the breakdown of costs for the medical services they received from the hospital.
2. Individuals who are required by their insurance company to submit a detailed statement of cost for reimbursement purposes.
3. Patients who plan on disputing any charges on their medical bill and need supporting documentation, such as a statement of cost, to present their case to the hospital or insurance company.
4. Individuals who are self-paying for their medical expenses and need a detailed breakdown of the costs incurred during their hospital visit for personal budgeting or tax purposes.

In summary, filling out a hospital statement of cost involves providing accurate personal and insurance information, specifying the period and dates of service, itemizing the services received, and including any additional documentation as required. This document is typically needed by patients who wish to understand their medical costs, seek reimbursement, dispute charges, or for personal financial planning purposes.

For pdfFiller’s FAQs

What is hospital statement of cost?

The hospital statement of cost is a document that details the expenses incurred by a hospital for providing medical services.

Who is required to file hospital statement of cost?

Hospitals are required to file the hospital statement of cost to report their financial information.

How to fill out hospital statement of cost?

The hospital statement of cost can be filled out by detailing all expenses related to medical services provided, including costs for personnel, supplies, and equipment.

What is the purpose of hospital statement of cost?

The purpose of the hospital statement of cost is to provide transparency and accountability of the hospital's financial activities.

What information must be reported on hospital statement of cost?

Information that must be reported on the hospital statement of cost includes details of expenses incurred for providing medical services, such as salaries, supplies, and equipment costs.

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