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Medical Payment Plan Agreement
"Need a Medical Payment Plan Agreement for our small clinic in Arizona to establish a 24-month payment plan for patients with outstanding balances over $5,000, with provisions for early payment and financial hardship adjustments to be implemented by March 2025."
1. Parties: Identification of healthcare provider and patient, including full legal names, addresses, and relevant identification numbers
2. Background: Context of medical services provided, resulting debt, and circumstances leading to the payment plan
3. Definitions: Key terms used throughout the agreement including Payment Plan, Services, Default, Interest, Late Fees, etc.
4. Payment Terms: Detailed terms including total amount owed, payment schedule, payment methods, and processing details
5. Interest and Late Fees: Terms regarding interest rates, late payment fees, and other applicable charges
6. Default Provisions: Conditions constituting default, consequences of missed payments, and available remedies
7. Representations and Warranties: Statements of fact and promises made by both parties regarding the debt and ability to pay
8. Termination: Conditions and procedures for ending the agreement, including early termination rights
9. Governing Law: Specification of applicable state law and jurisdiction
1. Insurance Coverage: Terms relating to pending insurance claims or partial insurance coverage of medical costs
2. Hardship Provisions: Procedures and terms for modifying the agreement due to financial hardship
3. Prepayment Rights: Terms allowing early payoff and any associated conditions or benefits
4. Collection Practices: Specific procedures and limitations regarding debt collection activities
1. Schedule A - Payment Schedule: Detailed breakdown of payment amounts, frequency, and due dates
2. Schedule B - Medical Services Statement: Itemized list of medical services provided and their associated costs
3. Schedule C - Patient Financial Assessment: Documentation of patient's financial situation if payment plan is income-based
4. Appendix 1 - Payment Methods: Detailed information about accepted payment methods and processing procedures
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