Payment Plan Agreement

Payment Plan Agreement Form

Please fill out the form to set up your payment plan. **ONLY complete this form if you were asked or requested by Cornerstone Psychiatric staff**
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Billing Address*

Street Address

Street Address Line 2
CityStateZip Code
Payment Plan Details:
Payment Method*

Credit or Debit Card (preferred method) --After you SUBMIT this form, please call us with your credit card details OR we will call you to verify your credit card information.Cash (you must stop in office to pay)
Date you want to start your first payment (MUST BE WITHIN 30 DAYS OF TODAY)*

MonthDayYear
Date
Enter your total account balance due ($):*
Select Payment Frequency based on 6 month payment plan. You can view the different payment amounts by selecting each option, then select one option that works best for you.*

Monthly (6 payments)Bi-weekly (12 payments)Weekly (24 payments)
This is your payment amount $ each time based on frequency. (Note: your final payment will be slightly more to equal your remaining balance due)*
Billing Information Confirmation

Please confirm that the information provided is accurate and complete.
I confirm that the information provided is accurate and I authorize Cornerstone Psychiatric Services, Inc to process the payment plan setup. If applicable, I will provide credit card details after CPS staff receiveds this agreement and I authorize my credit card to be processed according to the payment plan I selected.*

Yes, I agree and authorize
Date

MonthDayYear
Date
Should be Empty:

Payment Plan Agreement Form

Payment Plan Details:

Billing Information Confirmation