Free Medical Bill Payment Plan Template
Medical Bill Payment Plan
|
Patient Information |
Information |
|---|---|
|
Name |
[Your Name] |
|
|
[Your Email] |
|
Phone Number |
[Your Phone Number] |
|
Dental Insurance Details (if applicable) |
[Name of Insurance Provider] |
I. Introduction
This Medical Bill Payment Plan is designed to assist individuals who have incurred medical expenses not covered by insurance and require a structured plan to manage payment. The objective is to facilitate a manageable repayment process, ensuring that patients can meet their financial obligations without undue hardship.
II. Medical Provider Information
-
Provider Name: Springfield Medical Center
-
Address: 456 Health Blvd, Springfield, IL 62702
-
Phone Number: (555) 987-6543
-
Email: billing@springfieldmedcenter.com
-
Contact Person: [Contact Person]
III. Summary of Medical Bills
|
Service Date |
Description of Service |
Amount Due |
|---|---|---|
|
03/15/2050 |
Emergency Room Visit |
$1,200.00 |
|
03/16/2050 |
X-Ray Imaging |
$300.00 |
|
03/16/2050 |
Blood Tests |
$150.00 |
|
03/17/2050 |
Specialist Consultation |
$450.00 |
Total Amount Due: $2,100.00
IV. Payment Schedule:
The following payment schedule outlines the repayment terms for the total amount due.
|
Installment Number |
Due Date |
Amount |
|---|---|---|
|
1 |
06/01/2050 |
$350.00 |
|
2 |
07/01/2050 |
$350.00 |
|
3 |
08/01/2050 |
$350.00 |
|
4 |
09/01/2050 |
$350.00 |
|
5 |
10/01/2050 |
$350.00 |
|
6 |
11/01/2050 |
$350.00 |
Total Payments: $2,100.00
Note: Payments are due on the 1st of each month.
V. Interest and Fees
-
Interest Rate: 0% (No interest will be charged)
-
Late Payment Fee: $25.00 (applied if payment is not received within 10 days of the due date)
-
Other Fees: No additional fees apply unless specified otherwise in writing.
VI. Accepted Payment Methods
-
Credit/Debit Card: Visa, MasterCard, American Express,
-
Bank Transfer: [Account Number, Routing Number]
-
Check: Payable to [Provider Name], mailed to [Provider Address]
-
Online Payment Portal: [Link to online payment portal, if applicable]
VII. Authorization and Consent
By signing this Medical Bill Payment Plan, I, [Your Name], acknowledge and agree to the terms outlined above. I understand that it is my responsibility to ensure that payments are made on time and that failure to do so may result in additional fees and possible collection actions.
[Your Name]
[Date]
[Provider Representative Name]
[Date]
