Medical Service Payment Plan
I. Introduction
This Medical Service Payment Plan outlines the coverage, premiums, and benefits designed to ensure clarity and transparency regarding the financial aspects of receiving medical services.
II. Coverage Details
A. In-Network Services
Medical Services: General practitioner visits, specialist consultations, laboratory tests, hospital stays, surgical procedures, emergency care, preventive screenings, vaccinations, and physical therapy.
Provider Network: ABC Health Network, XYZ Medical Group, Community Hospital, Riverside Clinic, Greenleaf Pediatrics.
B. Out-of-Network Services
III. Premiums
A. Premium Structure
Monthly Premium: | Deductibles: | Co-payments/Co-insurance: |
$300 for individual coverage, and $600 for family coverage. | $1,500 individual / $3,000 family deductible. | $20 co-payment for office visits, 20% coinsurance for hospital stays. |
B. Billing Cycle
Billing Frequency: | Accepted Payment Methods: | Late Payment Policy: |
Premiums are due monthly. | Credit/debit card, electronic funds transfer (EFT), check. | A grace period of 30 days is provided for late payments, after which a penalty of 5% of the premium amount may apply. |
IV. Benefits
A. Medical Benefits
Preventive Care: Regular medical check-ups, vaccinations, cancer screenings, and pediatric care are essential for maintaining good health.
Diagnostic Services: X-rays, MRIs, CT scans, blood tests, biopsies.
Treatment Services: Surgery, chemotherapy, radiation therapy, dialysis, rehabilitation services.
B. Additional Benefits
Other Benefits: Chiropractic care, acupuncture, vision care (annual eye exam, partial coverage for glasses/contact lenses).
V. Contact Information
For any inquiries or assistance regarding this Medical Service Payment Plan, please contact:
By signing below, both parties agree to the terms and conditions outlined in this Payment Plan.
Name: [Your Name]
Date: [Date Signed]
Name: [Client Name]
Date: [Date Signed]
Plan Templates @ Template.net
