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Patient Payment Plan. I, _____________________________, the patient, (Account # ____________) understand that I am agreeing to the following payment plan between myself and Family Health Care Center. I further understand that I must sign this agreement for it to be valid.
MEDICAL (PATIENT) PAYMENT PLAN AGREEMENT I. THE PARTIES. This Legal Services Payment Plan Agreement (“Agreement”) dated _____, 20____, is by and between: Medical Office: _____, with a mailing address of _____, City of _____, State of _____, Zip _____ (“Creditor”), and
23 lip 2024 · A medical payment plan agreement is for a patient who has received health care services and agrees to pay their balance over a period of time. A medical payment plan usually does not have interest attributed to the amount owed unless the balance goes unpaid and is forwarded to a collection agency.
This payment plan details the total amount owed, the payment schedule, late payment policy, interest, and fees, as well as terms and conditions governing the agreement. We encourage patients to review this plan carefully and contact our billing department with any questions or concerns.
Sample patient payment installment plan in doc format comes handy if some patient is unable to pay the doctor’s fees or hospital charges and wants to repay this debt in installments. This template includes terms and also installment contract sample that specifies the payment details in advance.
2 sie 2014 · One way to ensure patients understand your payment requirements is to ask them to sign a payment policy. Here's a sample policy to consider adapting for your practice.
1. INFORMATION: Patient or guardian is responsible for notifying our office of any changes to demographics or insurance and billing information. 2. PAYMENT: Payment of your bill is considered part of your treatment. Fees are payable when services are rendered.
