Free Medical Payment Plan Template
Medical Payment Plan
I. Plan Overview
This Medical Payment Plan is established between [YOUR NAME] at [YOUR COMPANY NAME] and Ena Cassin to cover the cost of medical treatments and services. This plan outlines the payment structure, terms, and obligations to ensure consistent payments are made over an agreed period.
II. Total Amount Due
-
Total Cost of Services: $5,000
-
Initial Payment (if applicable): $500
-
Remaining Balance: $4,500
III. Payment Schedule
Payment will be made in monthly installments over the duration of this agreement.
|
Payment Due Date |
Payment Amount |
Remaining Balance |
|---|---|---|
|
February 1, 2055 |
$500 |
$4,000 |
|
March 1, 2055 |
$500 |
$3,500 |
|
April 1, 2055 |
$500 |
$3,000 |
|
May 1, 2055 |
$500 |
$2,500 |
|
June 1, 2055 |
$500 |
$2,000 |
|
July 1, 2055 |
$500 |
$1,500 |
|
August 1, 2055 |
$500 |
$1,000 |
|
September 1, 2055 |
$500 |
$500 |
|
October 1, 2055 |
$500 |
$0.00 |
Total Number of Payments: 9
IV. Terms and Conditions
-
Late Payments: A late fee of $50 will be charged if payment is not received within 10 days past the due date.
-
Early Payment Option: Payments may be completed early without penalty.
-
Payment Method: Payments will be made via credit card, bank transfer, or check.
-
Default and Termination: In the event of default (non-payment of 2 consecutive payments), [YOUR COMPANY NAME] reserves the right to terminate services or take further actions to recover the balance due.
-
Privacy and Confidentiality: All patient information is kept confidential and managed according to HIPAA guidelines and [YOUR COMPANY NAME]'s privacy policies.
V. Signatures
By signing below, both parties agree to the terms of this Medical Payment Plan.
Ena Cassin
Date: January 1, 2055
[YOUR NAME]
School Administrator
[YOUR COMPANY NAME]
Date: January 1, 2055
