Please complete the following form and click the 'Complete Entry' button at the bottom of the page.  In order to process this request, you will be required to verify that the information provided is complete and accurate.  A confirmation of receipt will appear once the form has been submitted.

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Please use your insurance card to provide the information below:
The information below, if known, will help us refine your estimate. (Click here for definitions)

* By checking this box, I acknowledge that I am requesting a cost estimate for a procedure(s) at Chambersburg or Waynesboro Hospital. I understand that the estimate will be based on the information I have provided herein. I confirm that, to my knowledge, this information is complete and accurate. I understand the estimate provided is not a guarantee of coverage and that, depending on my individual case, I may be held liable for other charges that are medically necessary as a part of my care or are not directly related to the services requested in this form.

How would you like to receive your estimate?

Postal Mail (Expect to receive a letter in 5-7 business days).
Please call me (Expect to receive a call within 2-3 business days).

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