Payment Plan

Payment Plan

Life happens. And with it, medical bills. We want to continue to support you. Thank you for setting up this payment plan to help address your balance. PLEASE NOTE YOU NEED TO BE ON A COMPUTER FOR SECURITY PURPOSES. NOT A CELL PHONE. We take your privacy and security very seriously. Sorry for any inconvenience.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Payment plan is for:

First NameLast Name
By signing below, I hereby authorize Collaborative Natural Health Partners LLC (“Collaborative Natural Health Partners”) to charge the payment method I have provided below the monthly payment plan every 30 days until my financial obligation has been met and my balance is zero. If payment dates fall on a weekend or holiday, I understand that the payment may be executed on the next business day. I understand that this authorization will remain in effect until I terminate it in writing. I agree to notify Collaborative Natural Health Partners in writing of any changes to my credit card information.
I certify that I am an authorized user of the payment method I have provided below, and that I will not dispute the scheduled payments with my credit card company, provided the transactions correspond to the terms indicated in this
authorization form. I agree to reimburse Collaborative Natural Health Partners its out-of-pocket costs, for any chargebacks I request.
I understand that I will continue to receive monthly statements and can/should pay more against my balance if possible. Any change to this payment plan agreement, I agree to provide at least seven (7) days written notice of cancellation prior to my next monthly membership fee billing.
Signature

Payment Plan Options

Payment Plan

Please make a monthly payment against your account.

USD for each month

Credit Card

Should be Empty: