Pine Street Family Practice
Payment Agreement
Date _____________________
Patient ___________________
Date of birth ___________
Please return this signed agreement with your first payment which
is due on _________________________.
I agree to make a payment of $________________ monthly
Amount
for the office visit/visits on __________________________
outstanding balance of _________________ .
The balance will be paid in full by _______________________ .
If your monthly payment is not received by the 15th of each month
the balance of account will be sent to collection agency. A 25%
collection fee will be added to the account. If this account is
already with our collection agency and payment is not made you
will be dismissed from our practice.
____________________________
Patient/Guardian
_____________________________
Witness