Financial Assistance

It is the policy of Good Samaritan Hospital (GSH) to collect all out-of-pocket expenses due prior to or at the time of service. If you are not contacted prior to your date of service, you may be visited by a financial counselor while receiving services to review your benefit package. The financial counselor will inform you of any out-of-pocket expenses for which you may be responsible and collect payment prior to discharge. If you are unable to pay at the time of service, the financial counselor will be able to discuss other payment options with you.

Any amount not paid by your health insurance plan within a reasonable amount of time will also be billed to you. If you have questions about your insurance benefits, contact your insurance company. If you have questions about your billing statement, you may contact us at (937) 276-8308, or toll-free at 800-772-1130, Monday – Friday, 8:00 a.m. to 4:30 p.m.

GSH Payment Options

Your payment’s due date will be listed on your statement. You may pay your account using cash, check, Visa, MasterCard, Discover, or American Express. Payment can be made in the following convenient ways:

• By mail: Please detach the bottom portion of your billing statement and include it with your payment in the envelope provided.
• By phone: We can accept a credit card payment over the telephone at (937) 276-8308, or toll-free at 800-772-1130, from 8:00 a.m. to 4:30 p.m., Monday – Friday. Be sure to have your account number available when you call. Your account number is listed at the top of your statement.
• In person: Payment is accepted at GSH’s cashier's office, located on the first floor, near the main entrance to your left. Office hours are 8:00 a.m. to 5:00 p.m. Office staff can be reached at (937) 276-2612, ext. 1342 or 1345.

GSH Payment Plan

As a service to our patients, GSH offers payment plans for those who are unable to pay their balance in full. To set up a payment plan, you may contact one of our customer service representatives at (937) 276-8308, or toll-free at 800-772-1130, from 8:00 a.m. to 4:30 p.m., Monday – Friday.

Financial Assistance

GSH offers additional assistance for patients with limited resources and insufficient insurance coverage. Financial counselors are available to assist patients in applying for many local, state, and federal programs that provide funding to help families pay for medical expenses. If you don't qualify for any of these programs, you may qualify for a financial assistance program offered through our hospital.

Patients who qualify for payment assistance will need to fill out the Hospital Care Assurance Program (HCAP) and Financial Assistance Program (FAP) application forms. Income verification documents may be required with the application.
 
You may request the form by calling (937) 276-8308, or toll-free 800-772-1130, from 8:00 a.m. to 4:30 p.m., Monday – Friday.

When you receive the form, fill in the required information and return the completed form to:

Care Assurance / Financial Assistance Program
Good Samaritan Hospital
P.O. Box 10160
Dayton, OH 45402-7160