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OUR MISSION: To foster healing and health for the people and communities we serve.

Exempla Healthcare Patient Pricing Center Request

While we make every effort to ensure the accuracy of our price estimates, medical care and diagnostic testing can take different turns.  Hospital charges are sometimes greater than the estimated amounts, dependent on each individual's needs and medical circumstances.  We cannot determine in advance the exact cost of a procedure to include all possible additional charges that may arise in the course of treatment.  Therefore, please note that this is only an estimate and not a guarantee of the charges for this service.  

* Indicates required information
First Name * 
Last Name * 
Phone Number * 
Email Address * 
What is the best time of day to call you back with the estimate? 
7:00 AM - 3:30 PM * 
By what date do you need the estimate? 
If you are not the patient, please provide the Patient's Name:  
First and Last Name:  
If the patient has health insurance, please provide name of insurance provider. 
 
Which Exempla Facility do you plan to use for this service? * 


Will the test(s) or procedure(s) be done as: * 


Name of the test(s) or procedure(s) to be done: 
If you don't know the name of the test(s) or procedure(s), please describe as best you can: 
Description: 
What is the name of the physician ordering/performing the test(s) or procedure(s)? 
First and Last Name 
Did your physician provide you with any detailed code information for the test or procedure such as a CPT or an ICD-9? 
If so please provide: 
If you would like us to send you a written estimate of charges, please provide an address: 
First and Last Name 
Street Address 
City 
State 
Zip Code 
 

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For patient billing inquires please contact Revenue Service Center at 1-866-665-2636 | 500 Eldorado Blvd. Suite 6300, Broomfield, Colorado 80021