Employee Discount Request Form

Employee Discount Form

  • To locate your account number, please refer to the upper right hand corner of your statement.
  • I would like to apply the above amount toward payment on my account 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.