PLEASE SEE BELOW FOR THE BREAKDOWN OF CHARGES THE

PLEASE PRINT THIS FORM AND TAKE A COPY TO
X PLEASE COMPLETE THE REQUIRED INFORMATION IN ADDITION THE
6 COVER SHEET (PLEASE USE THIS SHEET

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ACC 4152 IMPAIRMENT ASSESSMENT (ACCREDITED EMPLOYER) REPORT PLEASE
Associate Application Form (please Print and Complete
BLACK HISTORY MONTH 2007 EVALUATION FORM PLEASE

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Please see below for the breakdown of charges:

Please see below for the breakdown of charges:

The cost estimate breakdown for the surgical plan provided is as follows:

Professional Charges: $19,850
(Surgeon, MD Visits, Anesthesiologist,
Pathologist)

Facility Charges: $36,475
Room and Board, Medications
Pre-Adm testing, Labs, Diagnostics,
Imaging

Operating Room, Anesthesia, Recovery $22,079
Room & Medical Supplies

Pathology & Post-Operative Respiratory &
Physical Rehab $ 4,273


The remainder of the deposit being requested is to be applied towards the expected services at NY Presbyterian Hospital (PICU days and related services).


The cost estimates are based on similar cases and the actual costs can be more or less than the estimate costs. The actual costs will depend on what actually happens during surgery and the post operative recovery period.


Best Regards,

Eman Assas
Guest Services Coordinator
MSK International Center
Phone: 212-610-0871
Fax: 212-639-4938

CLIENT DETAILS FORM PLEASE COMPLETE THE INFORMATION
CREDIT APPLICATION – TRANSMISSION A PLEASE REFERENCE
DATE PLEASE FILL IN TO THE

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