formisoft

Payment Plan Agreement Form

Asks about account number, total balance owed, and monthly payment amount. Built for medical practices formalizing installment plans for outstanding balances.

Questions
10
Page
1
Time
about 3 min

Includes

  • Consent agreement
  • Insurance details
  • Card payment
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Your practice

Payment Plan Agreement Form

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Insurance Information

Live preview. Tap through it like a patient.

Who it is for

  • Medical practices formalizing installment plans for outstanding balances
  • Hospitals offering structured payment arrangements before collections escalation
  • Dental offices setting up monthly payment plans for major procedures
  • Billing departments standardizing payment plan terms across the organization

Formisoft for Dental

What's inside

Before you publish: Review amounts, payment terms, and authorization wording for your practice before sharing.

  1. Patient NameText · Required
  2. Account NumberText
  3. Total Balance OwedNumber
  4. Monthly Payment AmountNumber
  5. Number of InstallmentsNumber
  6. Payment Start DateDate
  7. Online PaymentPayment
  8. Payment Plan AgreementConsent Agreement
  9. Date of BirthDate
  10. Insurance InformationInsurance Info

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Payment Plan Agreement Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Payment Plan Agreement Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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