Agreement Terms
1. This is an interest-free payment plan as long as payments are made on time per the agreed schedule.
2. Payments will automatically be charged on the date mentioned above.
3. A $10 fee will be applied for any failed or declined payment.
4. Payment dates are pre-established and fixed. It is the patient’s responsibility to ensure funds are available on the scheduled date. No prior notice will be given before processing payments.
5. Requests to change payment dates must be made in advance and are subject to approval.
6. Missed or repeated failed payments may result in cancellation of the payment plan and full balance becoming immediately due
Authorization & Acknowledgment
I understand and agree to the terms of this payment plan. I authorize the provider to securely store my payment information and charge my card according to the agreed payment schedule.