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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