It is Premier Health's (Premier) policy to collect all estimated out-of-pocket expenses due prior to or at 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 estimate any out-of-pocket expenses that you may be responsible for 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 can contact us at (937) 208-2777(937) 208-2777 or (855) 208-2777(855) 208-2777, Monday - Friday, 8:00 am to 4:30 pm.
Your payment is due upon receipt of your statement. You may pay your account using cash, check, Visa, MasterCard, or Discover. 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) 208-2777(937) 208-2777 or (855) 208-2777(855) 208-2777, from 8:00 am to 4:30 pm 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 the Good Samaritan's Hospital Cashier's Office located on the first floor near the main entrance to your left.
As a service to our patients, Premier offers payment plans for those who are unable to pay their balance in full. To set up a payment plan, you can contact one of our customer service representatives at (937) 208-2777(937) 208-2777 or (855) 208-2777(855) 208-2777, from 8:00 am to 4:30 pm Monday - Friday.
Premier 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 Form. Income verification documents may be required with the application.
Premier Health's financial policy, a summary of the policy, and a financial assistance application form can be downloaded below. You can also request any of these forms by calling (937) 208-2777(937) 208-2777 or (855) 208-2777(855) 208-2777, from 8:00 am to 4:30 pm Monday - Friday.
When you receive the forms, fill in the required information and return the completed forms to:
Care Assurance / Financial Assistance Program
Good Samaritan Hospital
PO Box 932715
Cleveland, OH 44193-0015
Premier Health's financial assistance program applies to qualifying services provided by Premier Health hospitals only. During your course of treatment, you may receive services from other providers who are not covered by this program. A list of these providers can be obtained online. These providers may offer their own financial assistance program; please contact them directly to inquire. Because our provider list changes periodically, certain providers may not appear on the list. If you cannot find a particular provider, you may contact our Customer Service department at (937) 208-2777(937) 208-2777 or (855) 208-2777(855) 208-2777 for confirmation.
Content Updated: May 18, 2016