Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Payment Plan Agreement Form
Patient Name *
Account Number
Total Balance Owed
Monthly Payment Amount
Number of Installments
Payment Start Date
____ / ____ / ________
Payment Plan Agreement
Your practice's consent wording goes here.
Signature
Date
Date of Birth
____ / ____ / ________
Insurance Information
Carrier
Member ID
Group number
Subscriber name
Payment Plan Agreement Form template from formisoft.com. formisoft.com/intake-templates/payment-plan-agreement