Payment Plan

Payment Plan

To set up a payment plan, please fill out the following form. You will receive an additional form to fill out to provide us with your credit care/debit card information. If you have questions about either of these forms, please contact our office at 701-264-5200 or email billing@canopymedicalclinic.com. Charges will be applied based on your selections below until your past due balance is resolved.
Monthly Payment Plan Amount:

50.00 per month100.00 per month200.00 per month
Monthly Payment Withdrawal Date:

The 1st of every monthThe 15th of every month
Consent

By signing below, you authorize Canopy Medical Clinic to process your card as the "Card on File" and charge in accordance with the payment plan options selected above. This authorization will remain in effect until the expiration of the credit card or until your past balance is paid off. You can revoke this payment plan by submitting a written request. Canopy medical Clinic will only store the last 4 digits of your credit card information, and will keep your information private and secure.
Patient Legal Name*

First NameLast Name
Full Name on Card*

First NameLast Name
Billing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Credit Card Number*
Expiration Date*

MonthDayYear
Date
CVV*
Signature of Credit Card Holder: By signing this form, your verify you are the legal owner of this card, and that you have authority to place this card on file. *

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