Medical Bill Payment Plan
Patient Information | Information |
|---|
Name | [Your Name] |
Email | [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]
Plan Templates @ Template.net
