The process to be a patient is very simple. You have to contact our staff via email or by phone. We have an international number, or you can email me personally that you as a patient request our medical services. Since we are an integral hospital, we have every medical specialty and we offer a wide variety of services, from MRI, lab tests, consultations, bariatric surgery, orthopedic surgery, cosmetic surgery, general surgery, urological surgery, and dental services.
We also have a dental center where we offer all kinds of services from dental cleaning and whitening, to bridges, implants, crowns, and other dental services that are requested around the USA.
Hospital Metropolitano Vivian Pellas is the most prominent in Nicaragua for medical and dental services. We are the only JCI accredited hospital in all of Nicaragua so if you want that medical assurance, then you will find it at Hospital Metropolitano Vivian Pellas.
We offer medical tourism as an alternative to just staying in say, the US or Canada because the cost of medical care and the waiting time is less here. Most of our US and Canadian patients say the quality of medical attention from the doctors and medical staff is not the same here as in the US; they feel that the personal care here in Hospital Metropolitano Vivian Pellas is better than in the US hospitals.
With regard to insurance, we accept Blue Cross, Blue Shield International, Aetna International, Cigna International, and BUPA International. Those are the top international insurance plans accepted at Hospital Metropolitano Vivian Pellas. We do accept about 20 more insurance plans that are international but we only accept those for hospitalization and program surgeries. If you come for an MRI or for consultation under one of these plans, even if the insurance says your policy covers that, we will not accept that coverage.
Every type of surgery has more competitive prices here in Nicaragua than in the US, but the difference is greater in surgeries such as cardiology, orthopedic, or bariatric surgeries. The reason for this is because in the US, cosmetic surgery has become so popular that any small clinic which can provide an official receipt even without a good certification can offer US $4,000 for a breast augmentation (for example) and our price for the same procedure is only $3,000. The $1,000 difference is not much. In contrast, if you need a knee replacement, I think it is about $30,000 right now in the US and that includes everything from the surgery to the doctor’s fees and pre-ops. Here in Hospital Metropolitano Vivian Pellas, we have a knee replacement package that includes pre-ops for only $9,500. That is a huge difference.
Bariatric surgery, which is one of our star surgeries along with orthopedic surgery, costs less than half the price in Nicaragua. In the US, it is $20,000 and here in Hospital Metropolitano Vivian Pellas, it only costs $8,000.
You are going to get different answers to the question of how much it costs for a housekeeper or maid in Yucatan and you are going to get people who will tell you that you are paying too much. We pay our house staff US $15 per day and here at the beach, we pay maybe a little higher than some but they are some good quality people that I can trust and I want the same people to come back all the time. 
In Portugal, people tend to eat out more than probably most countries in Europe because that is the lifestyle here. I have lunch near my office here and I get a 3-course meal for about €7 (US $8 or £5.20). 
Driving in Coronado, Panama, is just like driving anywhere. The Pan-American Highway is just like an American highway. Once you turn into Coronado, the roads are not that great but they are not unpassable or terrible, either. The reason behind some of the roads in Coronado not being that great is because the government does not maintain them. Coronado is a community so they the community is responsible for their road. The roads in some areas are dirt roads and some are paved. 
Yes, you can absolutely lower your US tax liabilities abroad . Living outside the U.S. creates amazing opportunities to lower your worldwide tax bill--sometimes even to $0. That's right, depending on your specific situation, you may be able to grow wealth while not paying tax to any government, all completely legally. 
Not even Goldilocks would have a problem with Ajijic. It’s “just right” and in the middle: not too cold, and not too hot. Ajijic is not too crowded, but with enough residents to have services: there’s a Wal-Mart close by, and dozens of great restaurants, day spas, etc. Guadalajara, at 40 minutes away by car, provides an international airport, high-end shopping, culture, first rate medical care, etc. just close enough to be convenient but not too close to be an...