Patient Union, A Medical Bill Transparency

Hospital

Address

City

State

Zip

Phone

Facility ID

Procedure

Code

------------------------------------------ If you have a bill, you can provide the information here ------------------------------------------

Service Date

Bill Price

After Insurance Price

Paid Price

Code	Description	Minimum Charge	Maximum Charge
Guideline Price

Code	Description	Hospital	Minimum Charge	Maximum Charge
Other Patient Paid Price