The person indicated above agrees to make an equal number of payments (designated below) on the balance listed in the Outstanding Balance field.
The individual signing this document agrees to make payments on this payment plan using their VISA, DISCOVER, or MASTERCARD on file with Mid-Atlantic Behavioral Health. This credit card will be kept on file by a 3rd party in a secure system owned by Authorize.net. The individual signing this document gives Mid-Atlantic Behavioral Health permission to run the credit card on file on the 10th day of each month for the amount noted in this payment plan until the balance is satisfied.
The person signing this document indicates they understand a missed payment as a result of their credit card being denied will cause their account to be considered "Past Due" and may result in the full outstanding account to be forwarded to the collection agency. In addition, the individual signing this document acknowledges that they may be discharged from Mid-Atlantic Behavioral Health for non-payment. The individual signing understands that if they are discharged from Mid-Atlantic Behavioral Health they will need to seek another provider for any and all services that were being provided by Mid-Atlantic Behavioral Health.
If the undersigned should be terminated from Mid-Atlantic Behavioral Health for non-payment of past due balances, they understand that Mid-Atlantic Behavioral Health reserves the right to not accept them as a patient in the future, even if full payment is later made to the collection agency. Individuals may request reinstatement, but reinstatement is not promised or guaranteed.
By signing this agreement, the individual is stating they have read it in its entirety (or it has been read to them), and that they understand and agree to the terms of this agreement.