Patients

Simply fill in the information including your account number (located on your printed bill). After submitting your information, one of our accounting representatives will process your payment. Click here to pay your bill on-line

If you have any questions about your bill, please call us at 320-312-2136.

How it Works

Your insurance will be filed for your medical services if you present your current insurance card at the time of registration.  Your insurance company may require pre-authorization or referral from your primary care physician (PCP) and may not pay without it.  We will verify with you that you have received prior approval from your insurance company or PCP referral at the time of registration.  After insurance has paid their portion, we will bill you for the balance.  You can contact the Business Office at 320-769-4393 if you need to update your insurance information.

Finance Charges

Finance charges of 1.5% will be added to all accounts that haven’t been paid in full after being at patient responsibility for more than 30 days.

Billing statements are run around the 18th of every month.  This consolidated monthly statement summarizes the activity on all your outstanding hospital and clinic accounts.  If you have any questions, please stop into the Business Office during our normal business hours (Monday-Friday 7:30am-5:00pm) or contact us by phone at 320-769-4393 or toll free 888-769-2164

To request a monthly payment arrangement please click on the link below.  This option will allow you to make a monthly payment towards your outstanding bill with Johnson Memorial Health Services.  Your request for a payment arrangement can be denied if the monthly payment amount does not meet the requirements of the Johnson Memorial Health Services payment policy.  You will be asked to increase your monthly payment amount if you incur additional charges in the future.  If you have further questions, please contact the Business Office at 320-312-2136.

 

Payment Arrangement Request Form

Please complete the form and mail it to the address provided at the top of the form.

Automatic Bank Withdrawal – To request a monthly automatic withdrawal from your checking or savings account to go towards your bill at Johnson Memorial Health Services, please fill out the form below.  Your request for an automatic withdrawal can be denied if the monthly payment amount does not meet the requirements of the Johnson Memorial Health Services payment policy.  You will be asked to increase your monthly payment amount if you incur additional charges in the future.  If you have further questions, please contact the Business Office at 320-312-2136.

Automatic Bank Withdrawal Requestpp

Please complete the form and mail it to the address provided at the top of the form.

To request an automatic monthly credit card payment to go towards your bill at Johnson Memorial Health Services, please fill out the form below.  Your request for an automatic credit card payment can be denied if the monthly payment amount does not meet the requirements of the Johnson Memorial Health Services payment policy.  You will be asked to increase your monthly payment amount if you incur additional charges in the future.  If you have further questions, please contact the Business Office at 320-312-2136.
Automatic Monthly Credit Card Payment Request Form

Please complete the form and mail it to the address provided at the top of the form.

If you have no insurance, you may qualify for a 15% discount through this program.  Eligible patients or the responsible party need to complete an application for the uninsured discount.  Please click on the link below for the Uninsured Discount Application.  If Johnson Memorial Health Services determines a patient does have insurance, we will reverse the uninsured discount and bill the insurance for the full amount.  If you have further questions, please contact the Business Office at 320-312-2136.
Uninsured Discount Application Form

Please complete the form and mail it to the address provided at the top of the form.

Charity Care Discount – The federal poverty income guidelines provide the initial framework to determine an individual’s ability to pay.  Factors include:  family size, and  income. To qualify for the Charity Care Discount, you must first apply for Medical Assistance with your county.  If you qualify for Charity Care, the balance is either discounted or the entire balance is adjusted, based on the sliding fee schedule.   For example, in order to qualify:

• 1 in household:  income needs to be <$27,702
• 3 in household:  income needs to be <$47,234
• 6 in household:  income needs to be <$76,532

See our Charity Care Policy for more information. Please click on the link for the Charity Care Discount Application.  If you have further questions, please contact the Business Office at 320-312-2136.

Charity Care Discount Application Form Charity Care Discount Application Form – Spanish

Please complete the form and mail it to the address provided at the top of the form.

If a patient would like an estimated bill or would like to request pricing information.  Please contact Jarrett Wager, Revenue Cycle Manager, at 320-769-4393 or by email [email protected].