Template
A written-scope quotation for medical travel: a blank template
A blank quotation to print and fill in, so the price points to a scope both sides can check.
A template to adapt, not legal or clinical advice. Last checked .
01
What this template is
This is a blank quotation for a medical travel service. It ties the price to the assessed service, and shows what is in it, what is not, and what changes it. Print it, or copy the fields into your own document.
It is a template to adapt. It is not legal or clinical advice. The treating clinician always sets the clinical scope. This form only records who set it and when.
02
Why a written scope matters
The CDC Yellow Book says medical tourists "should ensure that they understand which services are included as part of the cost for their procedures". It warns that some facilities "charge substantial fees for follow-up care in addition to the base cost." The NHS asks patients where follow-up will be and how much it will cost.
In India, the NABH standard for medical travel facilitators asks for "a detailed quotation of the package cost as per the requirement of the patient". NABH is the national accreditation board for hospitals. Its standard also asks: "Does the quotation include cost incurred for the attendants?" An attendant is a family member or friend who travels with the patient.
A written scope is a promise a patient in another country can hold an Indian provider to. The trade-off is time, since a full scope is slower to send than one figure in a chat. In my judgement that delay costs far less than a dispute after the patient has flown.
03
How to fill it in
Fill every field before the quote is sent. If a field does not apply, say so rather than leave it blank.
Quotation details
Quotation number, version and date
Number each version, so the patient can tell the current quote from an earlier estimate. Basis: field note
Prepared by, and released by
Name who wrote this quote and who approved sending it. Basis: field note
Assessment basis
Status of this price
Tick one. An estimate must never look confirmed. Basis: field note
- Estimate
- Confirmed scope
- Depends on clinical review
Service being priced
In words the patient can use, as the clinical team approved it. Basis: field note
Scope approved by
Name, role and date. The treating clinician decides the scope. Basis: field note
What the price assumes, and any review still needed
What the quote assumes so far, and who will do any review still to come. Basis: field note
What the price includes
Included services
One row per item: what it is, who gives it, and any limit. Basis: field note
| Service | Provided by | Limit that applies |
|---|---|---|
| Service, row 1 | Provided by, row 1 | Limit that applies, row 1 |
| Service, row 2 | Provided by, row 2 | Limit that applies, row 2 |
| Service, row 3 | Provided by, row 3 | Limit that applies, row 3 |
| Service, row 4 | Provided by, row 4 | Limit that applies, row 4 |
| Service, row 5 | Provided by, row 5 | Limit that applies, row 5 |
Follow-up and aftercare in the price
What follow-up is included, and whether it happens where the treatment does. Basis: CDC Yellow Book
Travel, stay and coordination
If offered, how each one links to the clinical service. Basis: field note
Costs for attendants
Whether costs for anyone travelling with the patient are included. Basis: NABH MVTF standard
Facilitation service charge
If an agency arranges the trip, state its charge before the work begins. Basis: NABH MVTF standard
How payment is made
Tick the route. NABH asks agencies to tell patients that cash is not accepted. Basis: NABH MVTF standard
- Directly to the hospital
- To the hospital through the agency
What the price does not include
Not included
Every item outside this quote, so nobody has to search old messages. Basis: field note
Depends on facts not yet known
For each, who will assess it and how the patient will hear. Basis: field note
Insurance still to confirm
What the insurer must confirm, and who will ask. Never assume cover. Basis: field note
Conditions and changes
Conditions for this price
What must be true for this scope and price to hold. Basis: field note
What triggers a new version
For example, a change after clinical review, or one the patient asks for. Basis: field note
Who approves a change
A clinical change goes to the clinical team first, then a new price is agreed. Basis: field note
If more care is needed later
Who will explain the terms that would apply. Make no blanket promise. Basis: NHS
Who to ask
Questions about the price
The person allowed to explain this quote, and how to reach them. Basis: field note
Questions about the clinical scope
The clinical contact. Operations passes these on and does not answer them. Basis: field note
Version history
Changes to this quote
Add a row for each new version. Basis: field note
| Version | Date | Reason for the change | Approved by |
|---|---|---|---|
| Version, row 1 | Date, row 1 | Reason for the change, row 1 | Approved by, row 1 |
| Version, row 2 | Date, row 2 | Reason for the change, row 2 | Approved by, row 2 |
| Version, row 3 | Date, row 3 | Reason for the change, row 3 | Approved by, row 3 |
Why each field matters is set out in the field note Transparent medical tourism pricing starts with a written scope
A quote filled in this way lets a patient abroad compare commitments, not just figures. That is how an Indian provider earns trust before anyone flies.