Online pricing request

Thank you for choosing Labette Health for you healthcare needs. We are committed to providing the cost and information to you, our customers. We believe that by providing this information, it will help you better understand your financial responsibility for the medical services that you might receive.

If you should have any questions, please call 620.820.5507 during the hours of 8 a.m. to 4:30 p.m., Monday through Friday.

*First name

*Last name

*Email address

*Phone number

*Physician's name

*Type of service

Description of service

*CPT# (May need to get from physician)

With contrast?

Yes No

*Is service scheduled?

Yes No

Please provide the following information so we can send a follow-up to the estimate.

*Mailing address

*City

*State

*Zip

If you would like to know what your approximate financial responsibility is going to be, please fill out the following information.

Insurance name

Policy number

Group number

Insurance company's phone number

Subscriber name

Patient's date of birth

We also have a financial assistance program available to those with no insurance. Would you like information about this program?

Yes No

By completing and submitting this form, you are giving us your permission to talk to either the centralized scheduling department or your physician for further information. You will either receive a telephone call or email from us within two business days regarding your request.

Pricing and charging

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