HTML Preview Agreement to Pay for Physician Services page number 1.
Agreement to Pay for Physician Services
I agree to pay for the services rendered by (name of physicians or practice), as indicated
below.
Date of Service__________________ ___ Payment in full
Date to be paid___________
___ Payment schedule as follows:
Date_____________ Amount to be paid___________
Date_____________ Amount to be paid___________
Date_____________ Amount to be paid___________
____ Payments will be made by cash or check
____ Payments will be made by credit card, which I authorize you to use:
Credit Card:
Visa____________________________________ Exp_______
MasterCard______________________________ Exp_______
American Express_________________________ Exp_______
Other___________________________________ Exp_______
Name as appears on card_____________________________
It is understood that if the patient misses payments, without prior notification and
agreement, the practice reserves the right to transfer collections to a collection agency.
__________________________________________
Name of Patient (print or type)
__________________________________________
__________________________________________
Patient Address
__________________________________________
Phone
_____________________________________ __________________
Patient Signature ________________________Date
Courtesy: Conomikes Associates