Ask for comparable written estimates
An advertised price may cover a different set of services from another clinic’s estimate. Ask each team to describe the proposed procedure, the number of visits, and the charges included. A lower quoted amount by itself does not establish whether an option is appropriate for you.
Use this worksheet to organize information supplied by the clinic. It does not estimate market prices, determine insurance benefits, or recommend a treatment.
Clarify what is included
Ask about the evaluation, imaging or laboratory work, procedure, materials, preparation, medications, facility charges, and follow-up. Confirm whether a proposed course involves repeated sessions and how additional visits would be billed.
- What exact procedure and purpose does the estimate cover?
- How many sessions or visits are included?
- Who bills for each part of care?
- What would be charged if the plan changes?
Confirm coverage and payment terms
Discuss the proposed service and billing details with your insurer before committing. The clinic’s statement about coverage is a starting point for that conversation. Ask about network status, prior authorization, and your estimated responsibility. Prior authorization does not guarantee that the plan will cover the cost.
Keep the estimate’s date and expiration. Ask for deposits, financing costs, cancellation and refund terms, and follow-up responsibilities in writing. Record unanswered questions rather than treating blank fields as zero cost.
- Preauthorization · HealthCare.gov
Your printable worksheet
Print this page and write on your copy. This worksheet does not collect or save your answers.
Clinic and professional
Proposed procedure and purpose
Estimate date and expiration
Evaluation and diagnostic charges
Procedure, materials, and facility charges
Number of sessions and cost of extra sessions
Follow-up included and responsible clinician
Insurance questions and estimated responsibility
Deposit and payment schedule
Cancellation, refund, and financing terms
Additional charges or unresolved questions
Clinic contact for clarification
Sources and editorial context
This reference was compiled from the sources below and has not received independent clinical review. Use it to understand terms and prepare questions for a qualified professional who can consider your circumstances.
- Discussing health decisions with your doctor · National Institute on AgingReference checked 2026-10-02
- Evaluating health information · National Library of MedicineReference checked 2026-10-02
- Preauthorization · HealthCare.govReference checked 2026-10-02