Submit Appointment Request

You've reached the Know the Costs® Appointment Request Page.

Fill out all required information and click submit request.
Have your doctor's order? Upload with your request.
Don't have your order yet? Submit your request anyway.
We can't process your request until we receive the order.
Ask your doctor's office to send it by either:
- Fax: (877) 582-3329
- Email: info@knowthecosts.com
Once your order is received, we'll confirm and process your request.
Important: Doctor's notes, visit summaries, or records from MyChart or other patient portals are not valid orders. We must receive an official order to process your request.

You've reached the Know the Costs® Appointment Request Page.

Fill out the required info and submit request.
If you don't have your doctor's order yet, submit anyway—but we can't process until received.
Doctor's notes or visit summaries from MyChart/patient portals are not orders. Ask your doctor's office to fax it to 877-582-3329 or email info@knowthecosts.com.

* indicates a required field.

Patient Information

First Name

Middle Initial

Last Name

Date of Birth

Gender

Cell Phone

Home Phone

Address

Address (2nd line)

City

State

Zip

Benefit Information

Policy Holder's Employer Name

Policy Number (on Know the Costs® card)

Procedure(s)

Procedure Description

Diagnosis

Add Another Procedure

Referring Physician

Name

Address

Phone

Fax

Order Files

Upload file(s)

Other

Any other information you’d like us to know.

By submitting this form, you consent to receive emails, phone calls, and text messages from Know the Costs® regarding your inquiry and other relevant information. Message and data rates may apply. You can opt out at any time by replying STOP to text messages or by using the unsubscribe link in emails. For more details, please review our Privacy Policy.