PAYMENT SCHEDULE CONTRACT

PAYMENT SCHEDULE CONTRACT
CLIENTS NAME
DATE OF BIRTH

MonthDayYear
Date
RESPONSIBLE PARTY INFORMATION
NAME
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
HOME PHONE
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
E-mail
example@example.com
EMPLOYER
JOB TITLE
PHONE
Format: (000) 000-0000.
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
SLIDING SCALE:  Yes  No FEE
INSURANCE:  Yes  NoSLIDING SCALE:  Yes  No FEE:How would you like to receive your statement (Choose one):It is understood and agreed upon if the above payments are not received as due each month. There is a $35 fee for any checks that do not clear as that is the amount our bank charges us for all returned checks we deposit. Failure to meet the terms of this contract will result in your account being turned over to collections and reported to the credit bureaus.
WHEN TO BE PAID

MonthDayYear
Date
Email% Amount of Deductible:MailClient Co-Pay
INSURANCE:  Yes  No
% Amount of Deductible
Client Co-Pay
How would you like to receive your statement (Choose one):

Each insurance company has their own policies for Mental Health Services and the financial benefit. Check with your insurance company for your plan benefits.

rd EMHS uses a 3 party servicer for collection of payment. AMH Physicians Billing Inc. amhbilling1@protonmail.com 503-930-9225

I GIVE MY PERMISSION FOR TREATMENT FOR MYSELF AND/OR MEMBERS OF MY FAMILY UNDER MY LEGAL CARE.
I AGREE TO THE ABOVE PAYMENT PLAN AND UNDERSTANT THAT I AM LIABLE/RESPONSIBLE FOR ANY
SCHEDULED APPOINTMENTS CANCELLED WITHOUT 24 HOUR PRIOR NOTIFICATIONS. I ALSO UNDERSTAND I AM

RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY.
SIGNATURE OF RESPONSIBLE PARTY
DATE

MonthDayYear
Date
WITTNESS BY
DATE

MonthDayYear
Date
Should be Empty:

PAYMENT SCHEDULE CONTRACT

RESPONSIBLE PARTY INFORMATION

I AGREE TO THE ABOVE PAYMENT PLAN AND UNDERSTANT THAT I AM LIABLE/RESPONSIBLE FOR ANY