Free Tentative Payment Plan Template
Tentative Payment Plan
This payment plan is made under the company, [YOUR COMPANY NAME].
I. Introduction
This payment plan outlines the schedule and terms for covering the costs of medical treatments or procedures for [Patient Name]. Our goal is to make medical care accessible and manageable within your financial means. Please read through the plan carefully and reach out if you have any questions or require adjustments.
II. Patient Information
Name: [Patient Name]
Email: [Patient Email]
Phone: [Patient Phone]
Address: [Patient Address]
III. Medical Service Details
-
Procedure/Treatment: Knee Replacement Surgery
-
Total Cost: $15,000
-
Initial Deposit: $3,000
-
Date of Service: June 15, 2024
IV. Payment Schedule
|
Due Date |
Payment Amount |
Balance After Payment |
|---|---|---|
|
[Due Date 1] |
[Payment Amount 1] |
[Balance After Payment 1] |
|
[Due Date 2] |
[Payment Amount 2] |
[Balance After Payment 2] |
|
[Due Date 3] |
[Payment Amount 3] |
[Balance After Payment 3] |
V. Terms and Conditions
1. Payments should be made by the specified due dates to avoid any late fees or penalties.
2. The patient agrees to the total payment plan and understands that failure to comply may result in additional penalties or the termination of services.
3. Any changes to the payment plan must be communicated in writing and approved by authorized personnel.
VI. Contact Information
If you have any questions or need further assistance, please contact us:
Name: [Your Name]
Email: [Your Email]
Phone: [Your Phone Number]
Thank you for choosing [YOUR COMPANY NAME] for your medical care needs. We are committed to providing quality service and support every step of the way.
