Common Contracts
1 similar Payment Agreement contracts
Patient Registration – Additional FormsPayment Agreement • July 25th, 2024
PAYMENT AGREEMENT I agree all payments and co-payments must be paid at the time of service. I understand in order to be eligible for the sliding fee scale I must provide proof of income. Proof may consist of my previous tax return, paycheck stubs (3), unemployment printout, etc. This information must be provided at the time of visit for the sliding scale to be offered. I understand if my account is 90 days past due, I will receive a letter stating I have to pay on my account or I am subject for my past due account being written off to bad debt. I understand partial payments will be accepted unless otherwise negotiated. INSURANCE FILING I hereby authorize Health Ministries Clinic (HMC) to furnish information to insurance carriers concerning my illness and treatments. I understand my insurance will be filed as a courtesy and I agree to be financially responsible for any balance due to Health Ministries Clinic, Inc. I understand failure to provide HMC with current, accurate insurance info
