How this works - fill the five steps top to bottom. The patient's estimate builds on the right as you go, and you can print it when you're done.
Visit typePatient & insurancePregnancyInsurance detailsDeductible dates
1

Visit type

Start here. Is this a new pregnancy starting care with you, or a patient transferring in? This sets which charges apply.

First OB visit with us at 14+ weeks? Choose Transferring in: past visits are not billed and the right visit bundle is suggested.

2

Patient & Insurance Information

Who the patient is and which insurance plan they have.

Patient name is required
Date of birth is required

Provider Codes Reference:

MB - 155 834 6098 | AF - 167 906 1196 | HK - 106 391 6138
3

Pregnancy Information

Due date and which pregnancy services this patient needs.

4

Insurance Details

Deductible, out-of-pocket, and how each service is billed. Allowable rates fill in automatically from the plan.

Insurance Options:

Next Plan Year Insurance Information

These values are used when EDD or specific procedures fall in the next calendar year

Payment Method Selection by Procedure:

Confirmation Visit:
Sonograms (FTS, 20-Week):
Global OB:
Legend:
• Copay: Fixed copay amount applies
• Co-Ins: Coinsurance percentage applies
• CI/AD: Coinsurance Applied to Deductible
• Bill Insurance First: No upfront patient responsibility, bill insurance directly

Billing Options:

Note: Enable for patients with 100% coverage on certain procedures. When enabled, covered services will show $0 patient responsibility and insurance will be billed first instead of collecting upfront payment.
Insurance Allowable Rates(Auto-populated)

Note: These rates auto-populate based on your insurance selection but can be manually edited if needed.

5

Current Plan Year Deductible Info

The plan-year dates, so deductible math lands in the right calendar year.

Calculated Results

Updates live as you fill in the steps on the left. When it looks right, print the patient's form with the buttons below.

Estimated Patient Responsibility
$0.00
Global + ($350 Circumcision - If Applicable)
Insurance status
Remaining Deductible
$0.00
Remaining Out-of-Pocket
$0.00
Charges
Confirmation Visit
$0.00
FTS (First Trimester Screen)
$0.00
Separate charge if selected
20 Week Ultrasound
$0.00
Separate charge if selected

Enter 28-week date to calculate payment schedule

This is an estimate. Final billing depends on actual services and insurance processing.