Payment Plan Agreement by 7n2Mpe


									                                  Inglewood Family Health
                                    14048 Juanita Drive NE
                                        Bothell, WA 98011
                                Phone: 425-899-5300 Fax: 425-899-5304

If you would like to be set up on a payment plan, please complete the following with your first
monthly payment and mail back to us to have on record.

                                       BUDGET AGREEMENT

I _______________________, agree to the following payment plan with Inglewood Family Health (IFH):

Balance to be on payment agreement:

Minimum monthly payment:

To be received by IFH no later than the 25th of each month.

Payment amount today:                        Next monthly payment to begin 25th of October

I agree to make the minimum monthly payments until my account is paid in full or until reviewed in 6
months, which ever comes first.

I further understand that it is my responsibility to contact the bookkeeping office should I have
questions, concerns or possible changes related to my budget payment agreement.

I understand that required co-payments are due at each visit as well is the current balance on the
statements that I receive and are separate of any monthly budget payments made on my account. In
the event I am or become un-insured, I understand that I must make payment in full for visits, which
will also be entirely separate from my monthly budget payments.

In the event I fail to follow through with this agreement, I understand that I may be referred to an
outside collection agency and risk dismissal from Inglewood Family Health.

I have read and agree to the above budget plan:
                                                                        SIGNATURE                 DATE

Approved by the Billing Office at Inglewood Family Health:                             ____________
                                                                                       Initials of IFH

You will receive a copy of this once approved.

Thomas S Dawson, DO             Suzanne E Yeary, DO          Linda van Hoff, ARNP     Alice J Coad, ARNP

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