Price List and Written Estimate — Template
What it costs, before it is done. The public price list format and the written estimate a patient signs before admission or a procedure
What it is
A public price-list format (service, price, what is included, what is charged separately, state-programme coverage) and a written estimate template (procedure, itemised costs, exclusions, deposit, what happens if the plan changes, complaint route) — the ASF standard for financial transparency.
Where to use it
Price list at reception, on the website and on request; the estimate given and signed before any planned admission or procedure, with a copy in the record. Evidence for: Standard 2 — financial information and transparency; Universal Floor — patient rights; Medical Tourism endorsement. Evidence for: Standard 2 — financial information and transparency; Universal Floor — patient rights; Medical Tourism endorsement.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Patient Experience Survey — Fifteen Questions
Annual Public Report — Outline for an Accredited Organization
Print to share.
