Your Care Estimate

In all our services, Nebraska Orthopaedic Hospital strives to make your overall care with us as stress-free as possible. One aspect of your care that may be a question for you is the cost of your upcoming procedure. To help, we have prepared Your Care Estimate, an estimate cost of your care at Nebraska Orthopaedic Hospital. Please fill in all the information below and we will get back to you within 48 hours of your request with an estimate.

And as always, if you have any questions, please feel free to call us at 402.637.0600.

Required field are bold.

Personal Information
Patient First Name:
Patient Last Name:
Date of Birth:	-- 1 2 3 4 5 6 7 8 9 10 11 12 / -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / ---- 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909
Gender:	-- Male Female
Home Phone:	(xxx-xxx-xxxx)
Work Phone:	(xxx-xxx-xxxx)
May we leave a message on the patient's answering machine?	-- Yes No
How would like to be contacted with your care estimate?	-- Phone Mail Email
Street Address:
City:
State, Zip:	-- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ,
Email:
Insurance
Do you have health insurance?	-- Yes No
Name of Insurance:
Insured's Name:
Policy Number:
Procedure
Physician's First Name:
Physician's Last Name:
Procedure Scope:	-- Arm Elbow Fingers General Hand Fingers Hip Knee Leg MRI Shoulder Spine Therapy Wrist
Procedure:	--
By submitting this form, you give Nebraska Orthopaedic Hospital permission to contact your physician/insurance company if we need more information to complete your estimate. By submitting this form, you acknowledge that Your Care Estimate is an approximation of the cost of your procedure and care with Nebraska Orthopaedic Hospital and is subject to change.