Good Samaritan Hospital
* Hospital Reference Number/Account Number
(xxxxxxxx-xxxx or xxxxx):

* Guarantor/Patient Name:
* Patient Date of Birth (mm/dd/yyyy):
* Last 4 Digits of Patient’s SSN:
* Payment Amount:

Technical Support
If you need technical support for this online payment processing application, please send an email to gshfinancial@gshleb.org. A response will be provided within one business day.