Payment Plan Agreement

ProMed Ambulance Company offers flexible payment plans to help make medical bills more manageable. Payment plans must be set up within 30 days of your first statement, and the first payment is due at the time of enrollment. Plans may not exceed 12 months without approval from the Director of Revenue Cycle Management. If your account is Self-Pay, you may qualify for a 25% Prompt Pay Discount when the plan is created within 30 days, the first payment is made, and all scheduled payments are paid on time. Missed or late payments will cancel the discount and may result in referral to collections. After you complete this form, a member of our staff will contact you to securely collect your initial payment information. Your card details will not be stored on file. Monthly payments will then be billed automatically, and you will receive a final copy of your agreement once processing is complete.

Patient Name*

Date of Service*

Date

Phone Number*

Email*

example@example.com

Mailing Address*

Claim #*

Date of Birth*

Date

City, State*

Zip*

Acknowledgment of Terms. I understand and agree that:*

My payment plan must begin within 30 days of my first statement.My first payment is due today/at signing.If I qualify for the Prompt Pay Discount, it will remain valid only if Imake all payments on time.If I miss or delay a payment: The discount will be removed. The full balance will become due. My account may be referred to collections.No interest or finance charges will be applied to my account.My plan cannot extend beyond 12 months without approval from the Director ofRevenue Cycle Management.

Acknowledgment of Terms I understand and agree that: My payment plan must begin within 30 days of my first statement. My first payment is due today/at signing. If I qualify for the Prompt Pay Discount, it will remain valid only if I make all payments on time.

If I miss or delay a payment:

The discount will be removed. The full balance will become due. My account may be referred to collections. No interest or finance charges will be applied to my account. My plan cannot extend beyond 12 months without approval from the Director of Revenue Cycle Management.

Certification & Signature By signing below, I acknowledge that I understand and agree to the terms of this Payment Plan Agreement.