Susquehanna Health Medical Group (SHMG) will provide low, interest-free, monthly time payments for patients requiring the need to pay their guarantor balance due in installments following the SHMG payment contract guidelines.
To begin a payment contract with SHMG, print and complete the above form and send it in along with a $10.00 payment made payable to SHMG.
Send payment to: SHMG – 1201 Grampian Blvd – Williamsport, PA 17701.
Upon receipt of your complete contract form and initial payment, SHMG will send you a written notification of your required monthly payment amount.
The patient is responsible to make monthly payments and keep their account(s) current. Failure to maintain your monthly payment contract will result in forfeiting your right to contract payments.
Payment contract guidelines are based on the total guarantor balance owed.
|Account Balance||Monthly Payment Amount|
|$50 - $200||$10|
|$200.01 - $500 ||$25|
|$500.01 - $2,000||$50|
If the patient incurs additional balances while already on a payment contract, and their monthly payment needs to be increased, the SHMG Customer Service Department will notify the patient to discuss the account.
If you have questions regarding the SHMG payment contract option, contact our SHMG Customer Service Department at 1-800-223-3479 or (570) 326-8723. You may also visit us in person at 1201 Grampian Blvd - Suite 2B -Williamsport, PA 17701.