Patient Payment Plan Agreement

This Payment Plan Agreement is entered into between Anderson Bauman Chiropractic and the undersigned patient. This Agreement outlines the terms and authorization for a recurring payment plan toward the Patient’s outstanding balance.

Patient First name

Patient Last name

I, the patient (or Guardian), understand that I am agreeing to the following payment plan between myself and Anderson Bauman Chiropractic. I further understand that I must sign this agreement for it to be valid. All balances must be paid within the timeframe listed below. All unpaid balances 30 days or older will be considered for third party collections.

In today’s economic times, we understand the hardship you may be going through, and we want to work with you to resolve your balance. Listed below are our payment plan options.

Balance of Under $100 = Min Payment of $25/month

Balance of $100-200 = Min Payment of $35/month

Balance of $201-300 = Min Payment of $50/month

Balance of $300 or more = Min Payment of $100/month

I further understand that if claims are pending with insurance at this time that I may owe an amount in addition to the amount listed in my account and furthermore, agree to pay the amount based on this plan as well.

The monthly payment will be

Payment will be paid on the ___ of each month

I herby authorize Anderson Bauman Chiropractic to deduct the payment amount monthly on the day indicated above from my debit/credit card amount saved on file.

Patient Name & Account ID# (who's account payments will be applied to)

Any questions or concerns that I may have had concerning this agreement were answered or discussed with a staff member at Anderson Bauman Chiropractic. If this agreement needs to be altered at any time, I will contact the office manager, Carol Anderson , to discuss further options.

Email Address

Signature

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Todays Date

This Agreement may be completed and signed electronically. An electronic signature shall be considered the same as a handwritten signature for all purposes.

By submitting this form, you will be redirected to our secure billing website, Paywoot, where you can complete or update your payment plan (PlanPay).

Completion of both steps is required in order for your payment plan to continue under our current billing system.