The Craniofacial Center - Mam serce

The Craniofacial Center

Medical City Dallas Children's Hospital

Craniomaxillofacial, Cleft, Plastic and Reconstructive Surgery

Jeffrey A. Fearon, M.D., F.A.C.S., F.A.A.P. , Director

February 10, 2016

Mr. and Mrs. Konrad Matuszewski (Parents of Laura Matuszewski) Email: jolo5@vp.pl

Re: Surgery Case Cost Estimate Anterior Cranial Vault Remodeling) Surgery Cost Estimate is valid until May 10 2016

The following cost estimate for surgery has been prepared for your review

Hospital fee must be paid directly to Medical City Dallas Hospital (MCDH) at the time of registration. Please contact Julian Navarro at 972-566-7079 to make your payment of $20,520.00. The hospital accepts all major credit cards, cash, personal checks, cashier' s checks and money orders.

To assist you with your payment, Dr. Fearon accepts American Express, Discover, VISA, MasterCard, personal checks, money order' s and cashier' s checks. 50% Scheduling and Booking Fee in the amount of $6,000.00 is due to Dr. Fearon upon scheduling the surgery date . The remaining 50% in th amount of$6,000.00 is due to Dr. Fearon seven (7) days rior to the surgery dat . We do not acce >~ Wire Transfers. iAII fees arc ayable in US funds onl .

The Neurosurgeons fee of $4,060.55 must be paid directly to the office of Dr. David Sacco. Please contact Michelle Scheneman at 972-566-6900 to make payment arrangements.

The Anesthesiologists fee of $3,000.00 must be paid directly to the Anesthesiologists office once assigned to your case.

The fee for Pediatric Acute Care Associates must be paid directly to this entity. Please contact Alfreda Brown at 972-566-8340 to make your payment of $1,855.00.

The fee of $250.00 must be paid directly to the physician or hospitalist performing the Pre-operative History and Physical Examination at MCD. his exam may be erformed by your Rersonal .Rhysician.

If you have any further questions please do not hesitate to contact our office.

Sincerely,

Alondra E. Tip ?, Practice Admi tstr tor

7777 Forest Lane, Suite C700, Dallas, Texas 75230 Telephone: (972) 566-6464 FAX: (972) 566-6279 Cranio700@

The Craniofacial Center

SURGERY SCHEDULING AND BOOKING ESTIMATES

lfhe information below are estimates only and are subject to change and/or increase prior to payment in full.

Scheduling of any surgery requires the commitment of time and resources by your physicians and the hospital. Therefore, a 50% scheduling and booking fee is due to Dr. Fearon to confmn the surgery date. The balance of Dr. Fearon's fee is due seven (7) days prior to the surgery date. Dr. Fearon' s fee may be paid in full at the time of booking. Failure to make payment in full may result in cancellation of the surgery and forfeiture of the 50% scheduling and booking fee. If your surgery is cancelled for non-medical reasons prior to the surgery date, the 50% booking fee will be forfeited. If surgery is cancelled for medical reasons, a full refund will be made including the 50% booking fee with notice from your attending physician. Note: All fees to all providers are due prior to services being performed.

Surgery: Anterior Cranial Vault Remodeling

HOSPITAL CHARGES:

TOTAL FEE DUE to HOSPITAL

(i ncludes 2 days)

$20,520.00

(Additional days will increase fee by $1 ,700.00 per day to fee listed)

For additional information regarding the hospital fee, please contact Julian Navarro at Medical City Dallas Hospital at 972-566-7079.

Payment in full is due at the time of registration.

JEFFREY A. FEARON, M.D. - CRANIOFACIAL SURGEON: Anterior Cranial Vault Remodeling Split Skull Cranioplasty Sub-Total (54% discount applied) 02/10/16 TOTAL FEE DUE to Dr. FEARON

$16,014.00 $10,571.00 $26,585.00 $12,000.00

NEUROSURGEON- TBA:

Anterior Cranial Vault Remodeling

$6,247.00

(35% discount applied) 02/10/16

TOTAL FEE DUE to Neurosurgeon

$4,060.55

For additional information regarding the Neurosurgeons fee, please contact Michelle Scheneman at the office of David Sacco,

M.D. at 972-566-6900.

ANESTHESIOLOGIST - TBA:

$3,000.00

Anesthesiologist: (TBA)

Phone: (TBA)

For additional information regarding the Anesthesia fee, please call the Anesthesiologists office once assigned to your case.

PEDIATRIC ACUTE CARE ASSOCIATES ofNORTH TEXAS : (includes 2 days) (50% discount applied) 02/10116 TOTAL FEE DUE to PACANT (Additional days will increase fee by $100.00 per day to fee listed) For additional information regarding this fee, please contact Alfreda Brown at 972-566-8340.

$3,711.00

$1,855.00

HOSPITALIST FEE CHARGES:

$250.00

A RreoRerative history and physical examination is mandatory for all patients undergoing surgery.

his exam may be performed by your personal JJhysician. The report from a personal physician must be faxed to our office no later than

3 days prior to the surgery date. Please fax the form to FAX#: 972-566-6279.

Estimate for (Minor Child: Laura Matuszewski)

Estimate Date: 02/10/16

SUB-TOTAL in US Funds All Discounts A lied as of 02/10/16) ? Grand Total Due in US Funds

$60,313.00 $41,685.55

It is not uncommon to find you have further questions regarding the surgery process. Please do not hesitate to contact our office; we will be happy to assist yqu.

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