Payment Agreement


When a patient has no method of paying in full the copay, co-insurance and/or deductible due at the time of service, payment arrangements may be offered and a promissory note created.  The following payment plans may be offered. Based on approval from the Patient Account Representative. Payment for all elective procedure are due at the time of service.

  1. 50% at the time of admission and the remaining 50% due in 30 days.

  2. Promise to pay payments based on the Budget Plan Payment Agreement.


It should be explained and stressed to the patient that the payment plan is available only if all payments are made on time.  If a payment is more than 30 days late, the entire balance becomes due and payable.  The full balance will be due at the time the patient receives a billing statement. 

If these proposals are not acceptable any other arrangement, longer than 60 days, must be approved by management.

We only offer payment plans through our Patient Account Representative. Payment plans can only be arranged via auto draft (debit/credit card). If the patient is unwilling to provide the necessary information to set up an auto draft, then they must pay in full on or before date of service. Unless an authorized Budget Plan is signed and is followed according to the terms agreed upon. Once the necessary information has been entered into Pay Junction the automatic draft service, we will destroy all documentation regarding the patient’s bank and credit/debit accounts. We do not keep patient banking information on file