Healthcare Credit Agreement

HEALTHCARE CREDIT AGREEMENT

This Healthcare Credit Agreement ("Agreement") is entered into between Provider Name: with practice address: and Patient / Guarantor Name: .

PATIENT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY (SUMMARY)

AGREEMENT TERMS

1. Services and Amount Financed: Patient acknowledges receipt of services to be provided by Provider and agrees to finance the unpaid portion of such services. Total estimated charges: . Amount to be financed (principal): .

2. Down Payment: Patient will pay a down payment of at time of signing. Remaining balance: .

3. Finance Charge and APR: The annual percentage rate (APR) applied to the financed balance is . Finance charges will accrue as set forth in this Agreement.

4. Payment Schedule: Number of payments: ; Amount of each payment: ; Payments are due monthly on day of each month, commencing on .

PAYMENT METHOD

Patient authorizes the following payment method (select one or more):
ACH / Electronic Debit   Credit / Debit Card   Check by mail   Other:

If payment by card or ACH is selected, Patient authorizes Provider to store and charge the designated payment method for scheduled payments and any collection amounts permitted under this Agreement.

DEFAULT; LATE CHARGES; COLLECTION

1. Late Charge: A late fee of will be assessed for payments received more than days past the due date.

2. Default: If Patient fails to make required payments or otherwise breaches this Agreement, Provider may declare the entire unpaid balance immediately due and payable, pursue collection, charge reasonable collection costs and attorneys' fees, and report the delinquency to credit reporting agencies where permitted by law.

INSURANCE ASSIGNMENT & BENEFITS

Patient hereby assigns to Provider all rights to insurance benefits for services rendered to the extent necessary to satisfy the amounts due under this Agreement. Patient agrees to promptly provide insurance information and to cooperate with Provider's billing and claims submission.

AUTHORIZATIONS AND ACKNOWLEDGMENTS

I authorize Provider to obtain my credit report and other credit information as necessary to evaluate creditworthiness and manage this account. I certify that the information I have provided in this Agreement is true and correct to the best of my knowledge.

I authorize Provider to obtain credit information and verify financial information.

Patient understands that payments applied hereunder will be applied first to finance charges, then to principal, unless otherwise required by law or agreed in writing.

HIPAA / PRIVACY ACKNOWLEDGMENT

By signing below, Patient acknowledges receipt of the Provider's Notice of Privacy Practices regarding the use and disclosure of protected health information. Patient consents to communications regarding billing and financial matters by telephone, voicemail, mail, or electronic message to the contact information provided above.

I acknowledge receipt of the Notice of Privacy Practices and consent to billing communications.

AUTHORIZATION EXPIRATION

This authorization and any payment authorization provided under this Agreement shall expire on: . Unless revoked in writing prior to that date, Patient's authorizations remain effective and binding.

MISCELLANEOUS

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior understandings. Any amendment must be in writing and signed by both parties. This Agreement shall be governed by the laws of the state in which Provider's practice is located, to the extent not preempted by federal law.

Patient has the right to withdraw this Agreement within the period specified by applicable law by providing written notice to Provider; withdrawal does not eliminate liability for services rendered prior to withdrawal unless otherwise required by law.

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