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Payment Plan Agreement Form
Comments
This field is for validation purposes and should be left unchanged.
First Name
(Required)
Last Name
(Required)
Email
(Required)
Guarantor First Name
Guarantor Last Name
Account Number
(Required)
Original Balance
(Required)
Monthly Payment Amount
(Required)
Due Each Month
(Required)
Start Date
Month
Day
Year
Expected End Date
Month
Day
Year
Agreement Terms:
By signing below, the guarantor agrees to pay the balance identified above through monthly payments due on the agreed monthly due date. Failure to make a scheduled payment may result in delinquency, account lock, and return of the account to bad debt status under this policy.
Required Acceleration Clause:
In accordance with
IHM Part 9, Chapter 4, Section 9-4.12B (Acceleration)
, if the guarantor defaults on this payment plan, the full remaining unpaid balance becomes immediately due and payable, and the account will return to bad debt status.
The guarantor acknowledges receipt of this agreement, understands the payment terms, and understands the consequences of default.
FOR INTERNAL USES:
Revenue Cycle Representative ________________________________ Date ______________
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