Hospital Note for Patient-Initiated Promissory Agreement

Dear Patient,

This Hospital Note is prepared by Cooper Mirage from BlueHarbor Maritime with the purpose of helping you understand your commitment towards paying your hospital bill in installments. This document outlines the terms of the agreement, including the amount and frequency of each payment, and the consequences should you default on payments. While we strive to provide clear and concise information, please do not hesitate to contact us with any questions or concerns.

Terms of Promissory Agreement

Your hospital bill as of February 17, 2050 is as follows:

• Total Amount Due: $XXX

• Down Payment: $XXX

• Remaining Balance to be paid in installments: $XXX

• Number of Installments: XX

• Amount per Installment: $XX

Payment Schedule and Methods

Payments must be made on the agreed dates as per the given schedule until the balance is fully paid. To make the payments, you can choose from the following options:

1. Direct Debit

2. Credit/Debit Card

3. Cash or Check

Failure to Meet Payment Deadlines

If payments are not received according to the agreed-upon schedule, penalties (as outlined in our Late Payment Policy) may apply. Persistent non-compliance may warrant further action. If you're having trouble meeting your payment schedule, please discuss with us possible alternative arrangements.

Acknowledgements

By signing this Hospital Note, you acknowledge that you understand the agreement and commit to adhering to the payment schedule as outlined above. You agree that BlueHarbor Maritime Hospital has the authority to enforce the terms of this promissory agreement as necessary.

Cooper Mirage
BlueHarbor Maritime

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