Healthcare Insurance Payment Plan

HEALTHCARE INSURANCE PAYMENT PLAN

Patient Information

Emergency Contact

Insurance Information

Medical History (relevant to billing)

Payment Plan Agreement

Effective Date:

Total Current Balance (after insurance estimate): $ . This represents the sum of patient-responsible charges for services rendered through the Effective Date.

Payment Schedule: Patient agrees to pay a down payment of $ followed by installment(s) of $ each, due on day of the month beginning on .

Payments not received within days of the due date will incur a late fee of per month on the unpaid balance or a flat fee of $, whichever is greater. Returned payment fee: $.

Payment Methods & Authorization

Preferred Payment Method (check all that apply):

If paying by credit card or ACH, patient authorizes provider to charge recurring payments in accordance with the Payment Schedule above. Card or bank account must be kept current; patient will notify provider of changes at least 10 days prior to next scheduled payment.

Insurance Assignment & Financial Responsibility

By signing below, I assign to the provider all rights to insurance benefits for services rendered. I authorize release of medical information necessary to process claims. I understand the assignment of benefits does not relieve me of financial responsibility for charges not covered by insurance, including co-payments, deductibles, non-covered services, and remaining balances following insurance adjudication.

If insurance payment is delayed, reduced, or denied, I agree to pay amounts due under this Payment Plan according to the schedule. In the event of default, the provider may accelerate the balance, suspend services, and pursue collection remedies including reporting to credit reporting agencies and recovery of collection costs and reasonable attorney fees as allowed by law.

HIPAA / Privacy & Billing Notices

I acknowledge receipt of the provider's Notice of Privacy Practices and consent to the use and disclosure of my protected health information for purposes of treatment, payment, and healthcare operations necessary to administrate this Payment Plan.

Modification, Default & Termination

Any modification to this Payment Plan must be in writing and signed by an authorized representative of the provider and the patient. Failure to make two consecutive payments or otherwise breach the terms of this Agreement constitutes default and may result in termination of the plan and immediate acceleration of the entire unpaid balance.

Patient may request early payoff; provider will apply payments first to outstanding fees and then to principal unless otherwise required by law. This Agreement shall be governed by applicable state law where the provider maintains its principal place of business.

Authorizations & Expiration

Authorization Expiration Date: . Unless revoked in writing prior to that date, this authorization remains in effect for the duration of the Payment Plan and for any actions reasonably necessary to enforce its terms.

I authorize the provider and its agents to contact me at the telephone numbers and email provided for purposes of billing, payment reminders, and collection, including via automated or prerecorded messages where permitted.

Patient Certification

I certify that the information I have provided on this Payment Plan is true and correct to the best of my knowledge. I understand that I remain financially responsible for charges not covered by my insurance. I have read and accept the terms and conditions of this Payment Plan and agree to be bound thereby.

Sign Now