Quotation Estimate Surgeon in United States New York City –Free Word Template Download with AI

This Quotation Estimate is issued by Dr. Margaret A. Whitfield, a board-certified general and minimally invasive Surgeon practicing in the United States New York City metropolitan area, in response to the client's written request dated May 28, 2025. The following services are proposed for the surgical procedure, pre-operative evaluation, and post-operative care of the client. All services will be rendered at the Manhattan Surgical Center, a fully accredited facility located in the heart of United States New York City, in strict compliance with New York State medical regulations and the Joint Commission standards.

• Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, the Surgeon reserves the right to revise fees to reflect current market rates in the United States New York City healthcare sector.
• Payment Schedule: A non-refundable deposit of 25% ($6,658.10) is due upon acceptance of this Quotation Estimate. The remaining balance of 75% ($19,974.31) is due within fourteen (14) days following the completion of all post-operative follow-up visits. Insurance billing will be submitted directly to Empire BlueCross BlueShield; the client is responsible for any co-payments, deductibles, or amounts not covered under the policy.
• Surgeon Availability: The procedure will be scheduled within 30 to 45 days of the client's signed acceptance. The Surgeon will confirm the exact date, time, and pre-operative instructions no fewer than seven (7) days prior to the scheduled surgery.
• Cancellation Policy: Cancellation by the client more than 14 days before the scheduled procedure will result in forfeiture of the deposit only. Cancellation within 14 days will incur an additional 50% fee on the total Quotation Estimate amount. Cancellation by the Surgeon for non-medical reasons will result in a full refund of all deposits and fees paid.
• Medical Necessity: The Surgeon retains the right to modify the surgical approach, extend operative time, or recommend additional procedures if intra-operative findings warrant such changes. Any modifications will be communicated to the client (or designated emergency contact) as soon as safely possible, and additional costs will be itemized in a supplementary Quotation Estimate.
• Confidentiality: All medical records, imaging, and correspondence related to this engagement are protected under the Health Insurance Portability and Accountability Act (HIPAA) and New York State Public Health Law. The Surgeon and the Manhattan Surgical Center will not disclose client information without written consent.
• Governing Law: This Quotation Estimate and any resulting services agreement shall be governed by and construed in accordance with the laws of the State of New York, United States. Any disputes shall be resolved through binding arbitration in New York City, NY.
• Scope Limitation: This Quotation Estimate covers the specific services enumerated in Section 3. It does not include hospitalization beyond 23 hours, rehabilitation therapy, or any services not explicitly listed. Additional services will be quoted separately.

By signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of the proposed Surgeon services, associated costs, and terms, and authorizes the Manhattan Surgical Center and Dr. Margaret A. Whitfield to proceed with the scheduled procedure in the United States New York City. The client further consents to the surgical procedure described herein and to the use of general anesthesia.