I acknowledge this is an estimate and my actual total cost (i.e., the patient responsibility) may be different than the amount shown in the following estimate. Additionally, other services and items may be required for my procedure that are not included in this estimate and for which I may incur additional costs. Further, in the event I submitted information regarding a medical insurance plan, the cost estimate is based on the information Mon Health Stonewall Jackson Memorial Hospital has on file for such a plan and final coverage determinations are made by the plan. The use of any information provided by Mon Health Stonewall Jackson Memorial Hospital Patient Cost Estimate tool is confidential and intended to assist patients with their medical and financial decisions. Any attempt to use the Patient Cost Estimate tool for any purposes other than those intended by Mon Health Stonewall Jackson Memorial Hospital, as determined by Mon Health Stonewall Jackson Memorial Hospital in its sole discretion, is prohibited.

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