Oregon Cost Estimate Request Form

Recent Oregon legislation requires insurers provide policyholders with a reasonable cost estimate for specific in-network and out-of-network medical procedures or services in advance of receiving those procedures or services. We are required by law to provide cost estimates for the five most common procedures or services within the following categories: office visits, diagnostic radiology and imaging, diagnostic pathology/laboratory procedures, normal vaginal delivery, immunizations, orthodpedic-musculoskeletal surgery, and digestive system endoscopy. We are not required to provide procedures or services not included in these categories.

To receive your in-network or out-of-network cost estimate, please complete the information below. Or, if you prefer, you may call us toll-free at 1-800-MYAMFAM (1-800-692-6326), extension 78013 to speak to a Medical Services representative.

Estimate for Health Procedures Or Services

* indicates required information

First Name:*
Last Name:*
Phone:*	- -
Best time to call:*
Email:*

In order to provide an accurate estimate, please have the following information available when we contact you:

Type of procedure or service

Name and phone number of provider

Your policy number

Where the services will be performed

The provider’s billed charge amount (for out-of-network services)

Disclosures and Instructions

The cost estimate includes a verification of coverage. Benefits are based on medical necessity. There is no guarantee until your claim is submitted and reviewed.
The cost estimate does not include costs of unanticipated procedures or services. Services or procedures may be provided to you that are medically necessary and appropriate as part of the common procedures, of which you may not be aware at the time of the inquiry and for which you may have additional financial responsibility.
You may be responsible for the costs of procedures or services not covered by the plan.
Upon receipt of required information, the cost estimate will include the deductible, the amount of deductible that has been met by processed claims, coinsurance, copayment or other cost share to be paid by the enrollee for the procedure or service and any applicable benefit maximum. This information is accurate up to the moment that it is given.
Out-of-network estimates include the difference between the insurer's allowable charge and the billed charge for the service or procedure. In-network estimates will include the average payment or allowable charge for the procedure or service.
You may not be eligible for benefits if we can show that there was material misrepresentation on your policy or that the condition for which you are receiving treatment is a pre-existing condition.
You may contact American Family Insurance using the toll free number of 1-800-MYAMFAM (1-800-692-6326), extension 78013 for further explanation if the cost estimate differs from the actual cost or it you have any other questions.
The toll free number of the Oregon Insurance Divisions Consumer Advocacy Unit is 1-888-877-4894. The website address for the department of consumer information and complaints is: http://insurance.oregon.gov/.

I have read and understand the instructions and disclosures on this E-Form. I understand and agree that by clicking the checkbox preceding the statement, "I have read and understand the instructions", will serve as my electronic signature and will have the same force and effect as a manual signature.

Please click the 'Submit' button to submit the form to American Family Health Claims.