Medical (Patient) Payment Plan AgreementMedical (Patient) Payment Plan AgreementMedical (Patient) Payment Plan Agreement
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MEDICAL (PATIENT) PAYMENT PLAN AGREEMENT
I. THE PARTIES. This Legal Services Payment Plan Agreement (“Agreement”) dated
__________________, 20____, is by and between:
Medical Office: __________________, with a mailing address of __________________, City of
__________________, State of __________________, Zip _________ (“Creditor”), and
Patient: __________________, with a mailing address of __________________, City of
__________________, State of __________________, Zip _________ (“Debtor”).
HEREINAFTER, the Debtor and Creditor (“Parties”) agrees to the following:
II. BALANCE. At the time of this Agreement, the Debtor owes the Creditor the amount of
__________________ Dollars ($_________) (“Current Balance”) for medical-related services.
III. DISCOUNTED BALANCE. In consideration of the Debtor’s faith to repay the Current
Balance in this Agreement, the Creditor agrees to: (check one)
☐ - No Discounted Balance. The Debtor shall pay the full Current Balance (“Amount Owed”).
☐ - A Discounte