Medical Bill Payment Arrangement Agreement
Patient Name:
Account Number:
Provider Name:
Agreement Details
Total Amount Owed
Initial Payment
Monthly Payment Amount
Payment Due Date (Each Month)
Start Date
Final Payment Date
Terms and Conditions
The Patient agrees to pay the Provider the total balance in accordance with this arrangement.
Payments shall be made by the due date each month until the balance is paid in full.
If a payment is missed or late, the Provider reserves the right to cancel this arrangement and request payment in full.
This agreement does not waive any rights or remedies of the Provider.
Any changes to this agreement must be made in writing and signed by both parties.
Signatures
Provider/Facility Representative Signature
Date
Patient/Responsible Party Signature
Date