Request a Price/Cost Estimate

In an effort to make healthcare pricing less confusing and more transparent, OMC provides free price/cost estimates for our medical services/procedures. Our Patient Accounts team can help you understand the total price/cost of a service/procedure, which you (and/or your insurance provider) can use to determine how much you likely will pay out-of-pocket. Simply fill in and submit this secure form to get started! Our Patient Accounts team then will contact you by phone with any follow-up questions and/or your price/cost estimate.

Please note: this form is for patients who want a good-faith estimate of the price/cost of a medical service or procedure. If you wish to speak directly with an OMC representative about a price/cost estimate, please call our Patient Accounts office at 507.287.2780.

*Denotes required field

* Patient's First Name

* Patient's Last Name

* Date of Birth

* Mailing Address

* City

* State Example: NY

* ZIP Code Example: 12345

Please list Country if Outside US

Email Address

* Preferred Phone Number Example: 123-123-1234 x123

First Name (if not the patient)

Last Name (if not the patient)

Phone Number (if not the patient) Example: 123-123-1234 x123

Relationship to patient (if not the patient)

Health Plan

Health Plan Group Number

Health Plan ID Number

* Description of Services or Procedures

Location where services will be provided

CPT Code(s)

Comments

Verification: *

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