This is an agreement between Otolaryngology Associates, as creditor, and the Patient/Debtor named on this form.Associates Financial • June 21st, 2010
Payment Options: All previous balances are due at the time of service unless previous arrangements have been made with our Business Office. You may pay your out-of-pocket costs at the time of service by check, cash or credit card. Failure to make appropriate copayments at the time of service may result in a service charge of $10. If you are unable to pay your full out-of-pocket costs at the time of service, you may make payment arrangements through our Business Office by calling 703-573-5979. These options include a payment plan not to exceed three months on amounts less than $250.00 and six months on amounts over $250.00. Automatic payments can be arranged via credit card.
This is an agreement between Otolaryngology Associates, as creditor, and the Patient/Debtor named on this form.Associates Financial • April 30th, 2015
Payment Options: All previous balances are due at the time of service unless previous arrangements have been made with our Business Office. You may pay your out-of-pocket costs at the time of service by check, cash or credit card. If you are unable to pay your full out-of-pocket costs at the time of service, you may make payment arrangements through our Business Office by calling 703-383-7344. These options include a payment plan not to exceed three months on amounts less than $250.00 and six months on amounts over $250.00. Automatic payments can be arranged via credit card.
