Quotation Estimate Surgeon in United States Houston –Free Word Template Download with AI

Quotation Estimate No.: QTE-HOU-2025-04187 Date Issued: June 12, 2025 Valid Until: July 12, 2025 Prepared For: Dr. Margaret Ellison, MD, FACS

This Quotation Estimate is issued by MedStar Surgical Group, LLC, a licensed surgical practice operating in Houston, Texas, United States, to provide a comprehensive and itemized financial projection for the engagement of a board-certified Surgeon for specialized surgical procedures. This document serves as a formal Quotation Estimate outlining all anticipated costs, professional fees, facility charges, and ancillary services associated with the Surgeon's engagement. All pricing reflected in this Quotation Estimate is specific to operations conducted within the United States Houston metropolitan area and complies with the fee schedules established by the Texas Medical Board and applicable federal healthcare regulations.

The Surgeon referenced in this Quotation Estimate is a board-certified general and minimally invasive surgeon with over fifteen years of clinical experience in the United States Houston region. The Surgeon holds active licensure with the Texas State Board of Medical Examiners, maintains board certification through the American Board of Surgery, and is affiliated with Memorial Hermann Medical Center and Texas Medical Center in Houston. The Surgeon's expertise encompasses laparoscopic procedures, open abdominal surgery, hernia repair, bariatric surgery, and complex soft-tissue reconstruction. All credentials, malpractice insurance coverage, and hospital privileges have been verified as of the date of this Quotation Estimate.

#	Service / Item Description	Quantity	Unit Rate (USD)	Subtotal (USD)
1	Surgeon Professional Fee – Pre-operative Consultation and Patient Assessment (Houston, TX)	2 sessions	$450.00	$900.00
2	Surgeon Operating Room Fee – Primary Surgical Procedure (Laparoscopic Cholecystectomy)	1 procedure	$4,200.00	$4,200.00
3	Surgeon Anesthesia Coordination and Intra-operative Monitoring	1 procedure	$1,850.00	$1,850.00
4	Surgeon Post-operative Follow-up Visits (Week 1, Week 2, Week 6)	3 visits	$325.00	$975.00
5	Facility and Operating Room Charges – Memorial Hermann, Houston, United States	1 admission	$6,750.00	$6,750.00
6	Surgical Supplies, Implants, and Disposables (as applicable)	1 package	$2,340.00	$2,340.00
7	Pathology and Laboratory Services (pre- and post-operative panels)	1 set	$680.00	$680.00
8	Surgeon On-call and Emergency Availability Retainer (30-day period, Houston area)	1 month	$1,200.00	$1,200.00
9	Medical Records, Coding, and Administrative Processing (United States compliance)	1 case	$425.00	$425.00
10	Contingency Allowance for Unforeseen Intra-operative Findings (10%)	1 estimate	$1,932.00	$1,932.00
TOTAL ESTIMATED COST (USD)				$21,252.00

Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date, all fees and rates are subject to revision based on current United States Houston market conditions and provider fee schedules.
Payment Schedule: A deposit of 25% of the total estimated amount is due upon acceptance of this Quotation Estimate. The remaining balance is due within thirty (30) days of the completion of all surgical services and post-operative visits.
Insurance Coordination: MedStar Surgical Group, LLC will coordinate directly with the patient's primary insurance carrier. This Quotation Estimate reflects out-of-pocket estimates and may vary based on the specific insurance plan, deductible status, and coverage terms. The Surgeon's office will submit all claims in accordance with United States HIPAA regulations.
Scope of Services: This Quotation Estimate covers the specific procedures and services itemized in Section 3. Any additional procedures, extended hospital stays, or complications requiring further intervention by the Surgeon will be documented in a supplementary Quotation Estimate prior to additional treatment.
Surgeon Availability: The Surgeon's schedule is subject to change due to emergencies, medical leave, or hospital obligations. MedStar Surgical Group, LLC will make reasonable efforts to maintain the scheduled dates outlined in this Quotation Estimate and will notify the patient no fewer than seventy-two (72) hours in advance of any rescheduling.
Geographic Scope: All services described in this Quotation Estimate will be performed at licensed facilities within the United States Houston metropolitan area, including but not limited to Memorial Hermann Medical Center, Texas Medical Center, and Houston Methodist Hospital.
Liability and Malpractice: The Surgeon maintains a minimum of $5,000,000 in professional liability (malpractice) insurance coverage, as required by Texas state law. This coverage is maintained throughout the duration of the engagement described in this Quotation Estimate.
Confidentiality: All patient information, medical records, and financial data associated with this Quotation Estimate are protected under the Health Insurance Portability and Accountability Act (HIPAA) and applicable Texas state privacy statutes.
Dispute Resolution: Any disputes arising from this Quotation Estimate shall be resolved through mediation in Harris County, Texas, United States, in accordance with the Texas Medical Practice Act.

By signing below, the patient or authorized representative acknowledges receipt of this Quotation Estimate, understands the estimated costs associated with the Surgeon's services in the United States Houston area, and authorizes MedStar Surgical Group, LLC to proceed with scheduling the described surgical procedures. This signature does not constitute a guarantee of a fixed price; actual charges may vary based on clinical findings, insurance adjudication, and any necessary modifications to the surgical plan.

Patient / Authorized Representative
Signature & Date MedStar Surgical Group, LLC
Authorized Agent & Date ⬇️ Download as DOCX Edit online as DOCX

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