Patient Payment Plan - Family Healthcare Center
23702 Hwy 80 East, Statesboro, GA 30461
Patient Payment Plan
I, _____________________________, the patient, (Account # ____________) understand that I am agreeing to the following payment plan between myself and Family Health Care Center. I further understand that I must sign this agreement for it to be valid. All balances must be paid within the timeframe listed below. All unpaid balances 30 days or older will be considered for third party collections.
1. In today's economic times, we understand the hardships you may be going through, and we want to work with you to resolve your balance. Listed below are our payment plan options.
Payment Plan
Minimum
Balance
Payment Amount
Under $100
$25 per month
$100 - $200
$35 per month
$201 - $300
$45 per month
$300 or above
$50 per month
2. My current patient account balance is $____________ as of (date) _____________.
Are claims still pending with insurance? (Circle)
Yes No
I further understand that if claims are still pending with insurance at this time that I may owe an
amount in addition to the amount listed above and furthermore, agree to pay that amount based
on this plan as well.
Patient's (or Guarantor's) Initials _______
3. The monthly payment will be $________ and payment will be due on the _______ of each month.
4. I hereby authorize Family Health Care Center to deduct the payment amount monthly on the day indicated above from my debit/credit card account:
Type of Card (Circle): Mastercard Visa American Express Discover
Account #: _______________________________ Expiration Date: _________ V-Code (3 digit security code): _________ Billing Address Street #: _________________ Billing Zip Code: _________
5. Any questions or concerns that I may have had concerning this agreement were answered or discussed
with one of the staff members at Family Health Care Center. If this agreement needs to be altered at any
time, I will contact the Office Manager, Brandi Waters, at 912-489-4090 ext. 23 to discuss further
options.
Patient's (or Guarantor's) Initials _______
______________________________ Patient or Guarantor Printed Name
______________________________ Patient or Guarantor Signature
______________________________ Date
______________________________ Witness: Staff of FHCC Signature
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- patient payment plan family healthcare center
- conditional waiver and release on final
- fixed amount agreement template usaid
- city of portland grant agreement no xxxx
- naa payment plan agreement
- payment agreement sample eforms
- agreement for the renovation
- short form prime contract between owner
- settlement agreement adr
- repayment agreement draft
Related searches
- roman family healthcare greenfield ohio
- blank patient care plan template
- tgh family care center tampa
- tampa family health center appointments
- tampa family health center patient portal
- family help center nevada
- tampa family health center osborne
- tampa family health center locations
- tampa family health center facebook
- tampa family health center doctors
- best practices healthcare center selah
- family healthcare patient portal html