1. Please complete all information on the form.
2. If you require assistance in completing this form, please call the
Business Office at 605-696-9000.
3. Please remember to bring your insurance cards and an identification
card when you arrive at the hospital.
1. One Person in household to receive billing statement.
2. If patient is 18 years or older they will be listed as guarantor.
3. If the guarantor is different please complete guarantor section.
Accident/Injury/Work Compy/Information (if applicable)