MEDICAL (PATIENT) PAYMENT PLAN AGREEMENT

I. THE PARTIES. This Legal Services Payment Plan Agreement (“Agreement”) dated

Date

, is by and between

Medical Office

, with a mailing address of

, State of

, Zip

(“Creditor”), and

Patient

, with a mailing address of

, State of

“Debtor

HEREINAFTER, the Debtor and Creditor (“Parties”) agrees to the following:

II. BALANCE. At the time of this Agreement, the Debtor owes the Creditor the amount of

Dollars

(“Current Balance”) for medical-related services.

III. DISCOUNTED BALANCE. In consideration of the Debtor’s faith to repay the Current Balance in this Agreement, the Creditor agrees to: (check one)

Dollars

No Discounted Balance. The Debtor shall pay the full Current Balance “Amount OwedA Discounted Balance. The Debtor shall only be obligated to pay the discounted amount of

Dollars

"Amount Owed" If the Debtor should default

under any of the terms of this Agreement, the Debtor shall owe the Creditor the Current Balance in addition to other penalties, fees, and any accumulated interest.

IV. REPAYMENT PLAN. To satisfy the Amount Owed, the Debtor agrees to repay the Creditor under the following terms:

a Down-Payment. The Debtor shall pay: (check one)

Down-Payment ofNo Down-Payment.

a Down-Payment. The Debtor shall pay: (check one)

b Interest Rate. The Amount Owed shall: (check one)

Bear interest at a rate of

percent

annually. The rate must be equal to or less than the usury rate in the State of the Debtor

Bear interest at a rate of

annually. The rate must be equal to or less than the usury rate in the State of the Debtor

Not bear interest.

Repayment Period. The Debtor shall repay the Creditor on a: (check one)

Date

, in the amount of

to be paid on the

Monthly basis beginning on

to be paid on the

of every month ending on

Date:

BiWeekly basis beginning on

or when the Amount Owed is paidinfull.

Date:

, in the amount

to be paid every fourteen (14) days ending on

Date:

or when the Amount Owed is paidinfull.

Weekly basis beginning on

, in the amount of

to be paid every seven (7) days ending on

Weekly basis beginning on

to be paid every seven (7) days ending on

Other.Other.

or when the Amount Owed is paid-in-full.

d Payment Instructions. The Debtor is required to pay the Creditor under the following instructions

V. LATE PAYMENT. Any partial or late payment under this Agreement shall: (check one)

Allow the Debtor to make payment within days provided the Debtor pays a late fee of

“Extension Period

Not be allowed and consider the Debtor in default.Allow the Debtor to make payment within days provided the Debtor pays a late fee of:

“Extension Period

If payment is not made within the Extension Period, this Agreement shall be in default.

VI. PREPAYMENT. The Debtor may: (check one)

Debtor shall pay the penalty of

Pre-pay the Amount Owed without penalty.Not prepay the Amount Owed. If the Debtor decides to prepay the Amount Owed, the

Debtor shall pay the penalty of

VII. CO-SIGNER. (check the appropriate box)

This Agreement shall have a Co-Signer known as

as the "Co-Signer” and agrees to the liabilities and obligations on behalf of the Debtor under the terms of this Agreement. If the Debtor does not make a payment, the Co-Signer shall be personally responsible and therefore is guaranteeing payment of the principal, late fees, and all accrued interest under the terms of this Agreement.

This Agreement shall not have a Co-Signer.This Agreement shall have a Co-Signer known as

VIII. DEFAULT. If for any reason the Debtor should not oblige to any section or portion of this Agreement, the Debtor shall be considered in default. Under such an event, the remaining balance of the Amount Owed shall be due within five (5) business days with the Debtor liable to pay all reasonable attorney's fees and costs of collection of the Creditor. In addition, the Creditor may reclaim any property or goods in connection with the Amount Owed, hold and dispose of the same, and collect expenses, together with any deficiency due from the Debtor, subject to the Debtor's right to redeem said items pursuant to law.

IXGOVERNING LAW.This Agreement shall be governed by, and construed in accordance

with, the laws of the State of

“Governing Law

X.SEVERABILITYThe unenforceability or invalidity of any clause in this Agreement shall not have an impact on the enforceability or validity of any other clause. Any unenforceable or invalid clause shall be regarded as removed from this Agreement to the extent of its unenforceability and invalidity. Therefore, this Agreement shall be interpreted and enforced as if it did not contain the said clause to the extent of its unenforceability and invalidity.

. ADDITIONAL TERMS & CONDITIONS

I. ENTIRE AGREEMENTThis Agreement contains all the terms agreed to by the Debtor and Creditor relating to its subject matter, including any attachments or addendums. This Agreementreplaces all previous discussions, understandings, and oral agreements.

IN WITNESS WHEREOF, the Parties have executed this Agreement as of the undersigned dates written below.

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