Payment Plan Arrangement

Payment Plan Arrangement

Cornerstone Psychiatric Services, Inc. (NOTE: This form is only to be filled out if requested by CPS staff based on your current account status. This is not to be used for a regular one-time payment on your account.)
Name*

First NameLast Name
Phone*
Email
example@example.com
Billing Address*
City*
State*
Zip*
Payment method*

Cash (You must come by the office to make your payments)Credit / Debit (Once submitted please call the office directly to provide your credit/debit card info OR someone from the office will call withing 24 hours to obtain this information)
Payment Start date (Must be within 30 days from todays date)*

MonthDayYear
Date
Total account balance $: *
Payment Frequency*

Monthly (6 payments)Bi-Weekly (12 payment)Weekly (24 payments)
This is your payment amount $ based on frequency selected:
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 receives this agreement and I authorize my credit card to be processed according to the payment plan I selected.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: