Employee Discount

Employee Discount Request Form

Please fill out the form completely and click "Submit"
to send to the Business Office

I would like to apply $ toward payment on account number for services rendered at Ransom Memorial Hospital.

I certify that all insurance benefits have been exhausted and the balance due is my responsibility.

I understand that if all employee discounts have been exhausted for the plan year, that I will be responsible for payment of these services.

(Signed by RMH employee)

Select Department

Today's Date (mm/dd/yyyy)

Patient Name