Reading Your Bill
Your Good Samaritan Hospital (GSH) bill reflects all of the services you receive during your stay. You may receive more than one type of bill. A copy of the financial assistance application is on the reverse side. If you think you may qualify, please complete, sign, and return to the address listed on the reverse side of the statement.
This bill reflects your room rate, medication, medical supplies, and services performed by hospital personnel. Upon request, an itemized bill can be sent to you after you are discharged and after we have billed your insurance company.
Private Physician Bills/Professional Services
A private physician's bill will include your personal physician's fee or fees charged for the professional services of anesthesiologists, pathologists, radiologists, emergency physicians, or other subspecialty physicians. These charges are not billed by GSH. Questions concerning these bills should be directed to the department or office listed on the bill.
After you leave, you may get other bills from medical specialists who helped us with your care. You may have met these specialists face-to face, or they may have helped behind the scenes, checking your X-rays or providing other professional services for you.
Example of a Patient Statement
Select the link below to see an example of a patient billing statement that you might receive. This example includes an explanation of what is on the bill.
Sample Patient Billing Statement
To view the sample patient billing statement, you will need Adobe® Acrobat® Reader, which you can download for free.
For Help With Your Hospital Bill
If you need an explanation of your bill or if you'd like to set up payment arrangements, please call us at (937) 208-2777 or (855) 208-2777, Monday - Friday, 8:00 am to 4:30 pm