Payment Plan Agreement
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1PAYMENT PLAN AGREEMENT
I, _____________________________________________________, agree to
remit the following payments to ____________________________________:
AMOUNT
PAYMENT DATE
Check #
Pmt 1
Pmt 2
Pmt 3
Pmt 4
Pmt 5
This payment plan is interest free and free of billing charges for the payment period; however, I
understand that in the event any of my payment is ___ days late, ________________ will add a
monthly finance charge to my account in the amount of _____ % (___% APR). Finance charges
will accrue from the original charge date. This fee is enforced to keep costs at a reasonable level,
thus preventing frequent increases in the fees for medical services.
Method of Payment:
________ Personal Check(s): See information above
Credit Card (Check one):
______ Visa®
______ MasterCard®
Credit Card Number: ______________________________ Expiration Date:_____________
I authorize _________________ to keep my signature on file and to charge my payments to the
credit card selected above.
__________________________________________________________ __________________
Signature of Responsible Party/Cardholder
Date
_____________________________________________________________________________
Print Name of Responsible Party/Cardholder
Print Patient Name(s)
_____________________________________________________________________________
Address
City
State
Zip
(____)___________________________________
Phone Number
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Parent category: Business