Common Contracts
1 similar Monthly Payment Agreement contracts
MONTHLY PAYMENT AGREEMENTMonthly Payment Agreement • August 5th, 2014
Credit Card Payment Plan Option: I authorize Northlake OB/GYN to debit the credit card listed below for the amount(s) and date(s) listed. I understand that Northlake OB/GYN will keep my credit card information confidential and the information will only be used for the purposes of this payment plan. If I do not pay for services rendered to the patient, and the account is turned over for collection, I agree to pay all costs, fees and expenses incurred by Northlake OB/GYN in collection or attempting to collect any amount due under this agreement.
