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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: Peking

How to fill out hospital statement of cost

How to fill out a hospital statement of cost:

1. Review the provided hospital statement of cost form. Familiarize yourself with the different sections and fields that need to be filled out.
2. Start by filling out your personal information accurately. This may include your full name, address, contact information, and any other details required by the form.
3. Next, provide your insurance information. This typically includes the name of your insurance company, policy number, and any other relevant details. If you do not have insurance, leave this section blank or indicate that you are uninsured.
4. If you have a specific medical condition or diagnosis, indicate it in the appropriate section of the form. This can help the hospital better track and categorize your expenses.
5. Ensure that you have all the necessary documentation for your visit to the hospital, such as itemized bills, invoices, or receipts. Attach these documents to the statement of cost form as instructed.
6. In the section for patient responsibility, indicate any expenses or costs that you are responsible for paying out of pocket. This may include deductibles, co-pays, or non-covered services.
7. Double-check all the information you have entered to ensure its accuracy. Mistakes or missing information can lead to delays or issues with processing your statement of cost.
8. Sign and date the form, affirming that the information provided is true and accurate to the best of your knowledge.
9. Submit the completed hospital statement of cost form to the appropriate department or individual within the hospital. Follow any additional instructions provided for submission.

Who needs a hospital statement of cost?

1. Patients who want to review their medical expenses and better understand the cost breakdown of their hospital visits may need a hospital statement of cost.
2. Individuals who need to provide proof of medical expenses for tax purposes or reimbursement from insurance companies may require a hospital statement of cost.
3. Patients who are uninsured or have high deductible health plans may need a hospital statement of cost to negotiate or manage their medical bills.

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