Benefit and Eligibility Disclaimer This is a good faith estimate based on the average cost for the service provided at the time of the estimate. The information related to the estimate may be provided by you, your physician or your insurer. Please contact your insurance company concerning your cost-sharing responsibility. Actual amounts for services rendered are likely to vary based upon your specific needs at the time of the service, determination by your physician and additional information provided by your insurer. Therefore, your final actual cost may exceed this estimate. This service may be available at a lower cost to you at another facility or healthcare setting. Final determination of eligibility and benefits is made at the time the claim is processed by your insurance company. Any services determined to be non-covered under your plan are your responsibility. Charges from physicians affiliated with the hospital for services rendered to you will be billed by their offices and are not included in this estimate. Memorial Healthcare System contracts with various physician groups that may not be a part of your insurance plan (view contracted Insurance Plans and Physician Groups). We recommend you follow up with your insurance company to determine your coverage. We have several payment options available for you: One option is to pay the amount in full. A second option is to pay a deposit and set up a monthly payment plan for the remaining balance. Another is to pay a flat rate and/or self-pay rate (if applicable). We also have a financial assistance program you may qualify for, which may entail providing detailed financial documents. Learn more about our financial assistance programs. If you have any questions, please call customer service at 954-276-5501. Our office hours are Monday-Friday 9 am - 6 pm. This document may contain privileged or confidential information that is legally protected. This information is intended only for the use of the recipient. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the content of these documents is strictly forbidden.