Voucher Process


Any patient who does not need or request financial assistance with medical bills should be treated and billed like any other patient.

If the patient requires financial assistance from Community Health Service Inc. (CHSI), a voucher must be presented or verbal authorization by a CHSI nurse may be necessary in some instances, such as pre-post season and for our Mobile Unit patients.

If patient is found to have commercial insurance CHSI will pay balance insurance states is patient responsibility up to our fee schedule limits.

If a patient is found to have medical assistance, please return voucher to CHSI to be voided.

Remember, CHSI’s reimbursement levels may not cover the complete cost of the visit. Any balance remaining after payment by CHSI is the responsibility of the patient or parent/guardian.  The only exception to this is when there is a signed Physician Fee Agreement in place, then the patient is only responsible for the balance of any charges for lab, x-ray and reading.  The balance of the office visit (CPT 99201-99215) after CHSI payment would be written off.

 Each patient must be currently registered with CHSI and have a voucher which is only valid for the date indicated.  Subsequent visits will require additional authorization/voucher.

The procedure to follow if the patient does not have a voucher is:

Ask the patient who will be responsible for the bill. If they say “Community Health Service Inc.”, please ask the patient for the following information:

  • Patient’s Name
  • Date of Birth
  • Head of Household
  • Local Address
  • Telephone
  • Home Base Address

Please call the local CHSI for authorization. Please see website for contact information. www.chsiclinics.org


Patients who have been seen by our Health Center staff and approved for a voucher, a voucher will be faxed to you.  Please follow these steps for completion:

  1. The voucher (single white sheet) requires attaching an itemized bill/statement which must include the CPT procedures codes(s) and ICD diagnosis code(s).  HCFA 1500 form is preferred. Dentists should attach a billing statement with the CDT code(s). Pharmacy should attach an RX label.2.
  2. The medical/lab report must be attached or the voucher cannot be honored for payment.

If you fax the voucher back to us, please fax to (218) 236-6507 ATTN Kim.

Before the Health Center closes, the nurse will make arrangements with you for any patients that have future appointments.  For anyone else, please call the Central Office at (218) 236-6502 or Toll Free 1-800-842-8693 before providing service.  Please refer to our guidelines in our Provider letter.

If vouchers are to be VOIDED – please return to central office with an explanation on why it is voided.

In 2017, if it appears our funds are rapidly depleting, we will give you advance notice.