Good Faith Estimate

What is a Good Faith Estimate?

A Good Faith Estimate shows a list of expected charges by the provider and facility for an upcoming procedure. This estimate is not a bill and is provided for individuals without health insurance or those who aren’t using insurance to pay for their care.

Learn more About Good Faith Estimates

Request A Good Faith Estimate:

To request a Good Faith Estimate, please complete the following form and a representative from Zotec Partner will contact you on behalf of MCAA within 24-48 hours.

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Thank you for your submission.

A representative from Zotec Partners will be in contact with you soon.

Patients First & Last Name

Requestor’s First & Last Name (if not the patient)

Requestor’s Phone Number

Requestor’s Email Address

Requestor’s Relationship to Patient

Patient’s Birthdate (YYYY-MM-DD)

Services to be Self-Paid or Insured?

Patient Mailing Address

Street Address

City

State

Zip Code

Patient’s Communication Preference

Primary Diagnosis CPT

Length of Surgery

Date of Treatment (YYYY-MM-DD)

Location of Treatment(required)

Piedmont Athens Regional Hospital Piedmont Athens Out-Patient Surgery Center Surgery Center of Athens

Surgeon’s Full Name