Billing Information  
 
  
Guarantor Name
   Patient Name/Acct Number
  
Company Name (optional)
  
First Name
 
MI
 
Last Name
   Address
  
  
City
  
State
  
Zip Code
  
Phone
  
Work Phone
  
E-mail (required for an emailed receipt)
  
 
   Payment Information  
  

Payment Amount
 
  Please select a payment method
Checking Savings Credit/Debit Card
  Notes

 
 
Payment Policy Notice

Please refer to your billing or statement that you have received in the mail from St. Luke, Home Health or the Hospital. Please read your billing thoroughly for all notices and payment arrangements.

Your billing will list the correct account number(s) that you will enter into the patient account number. Please use the free text note section to supply additional information specific to your account(s) such as the provider of the service, i.e. clinics, home health, home medical equipment or hospital.

Please list the name of the person making the payment and their current address and phone number. This number will be used to make contact if we can not identify the correct account.

Please refer all your billing questions to the business office at 620-382-2177, or email us at customer.service@slhmarion.org.


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