Medical Office Payment Plan
I. Introduction
Welcome to the payment plan offered by [Your Company Name]. This document outlines the structured agreement between the medical office and the patient regarding payment for medical services over time. We understand that managing healthcare expenses can be challenging, and our goal is to provide a transparent and manageable payment solution. 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. Thank you for entrusting us with your healthcare needs.
II. Company Information
Company Name: [Your Company Name]
Contact Person: [Your Name]
Address: [Your Company Address
Social Media: [Your Company Social Media]
Office Hours:
III. Patient Information
Name: [Patient's Full Name]
Date of Birth: [Patient's Date of Birth]
Address: [Patient's Address]
Phone Number: [Patient's Phone Number]
Email Address: [Patient's Email Address]
Insurance Information (if applicable): [Insurance Provider, Policy Number]
Total Amount Owed:
IV. Payment Schedule
The payment schedule for the amount owed is as follows:
DUE DATE | AMOUNT |
|---|
June 1, 2050 | $300.00 |
July 1, 2050 | $300.00 |
August 1, 250 | $300.00 |
September 1, 2050 | $300.00 |
V. Payment Method
Payments can be made via cash, check, credit card, or electronic funds transfer.
Please make checks payable to: [Your Company Name]
Credit card payments can be made over the phone or in person at the office.
VI. Terms and Conditions
A. Payment Obligation:
B. Late Payments:
A late fee of $25.00 will be charged for payments not received by the due date.
If payment is not received within 30 days, the account may be referred to a collection agency.
C. Interest and Fees
D. Termination of Payment Plan:
The medical office reserves the right to terminate this payment plan if payments are not made by the agreed schedule. In the event of termination, the full remaining balance will be due immediately.
E. Changes to Payment Plan:
Any changes or modifications to this payment plan must be agreed upon by both parties in writing.
F. Responsibility for Insurance Claims:
The patient is responsible for ensuring that any applicable insurance claims are submitted promptly and for providing accurate insurance information to the medical office.
G. Authorization for Communication:
The patient authorizes the medical office to communicate regarding billing and payment matters using the contact information provided.
H. Governing Law:
This payment plan shall be governed by and construed by the laws of the [State/Country].
I. Agreement
By signing below, the patient acknowledges that they have read and understood the terms and conditions of this payment plan and agree to abide by them.
[PATIENT'S NAME]
[DATE SIGNED]
Plan Templates @ Template.net
