[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-359019-105":53,"doc-detail-359019-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","patient-payment-plan-form","Patient Payment Plan Form","","This document provides a formal Patient Payment Plan agreement between the Family Health Care Center and its patients. It is designed to assist patients in managing outstanding account balances through structured monthly installments based on total debt. The form requires the patient to verify their current balance, acknowledge potential additional costs from pending insurance claims, and authorize recurring monthly payments via credit or debit card. It serves as a binding agreement that outlines financial obligations, collection policies for unpaid balances, and contact procedures for payment plan modifications or inquiries. By signing this agreement, the patient or guarantor commits to the specified payment schedule, ensuring transparency and professional financial administration between the medical facility and the individual. The document promotes clarity in healthcare billing practices by detailing card authorization requirements, including card type, expiration, and security codes, while identifying the Office Manager as the primary point of contact for financial resolution.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-payment-plan-form/359019/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-payment-plan-form/359019.png","ImageObject",442,249,{"name":88,"@type":89},"Aria Callaghan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-20","2026-09-23",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What are the minimum payment requirements based on the account balance?","Question",{"text":109,"@type":110},"The plan requires $25/month for balances under $100, $35/month for $100-$200, $45/month for $201-$300, and $50/month for balances $300 or above.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What happens if an account balance remains unpaid for 30 days or longer?",{"text":114,"@type":110},"Unpaid balances 30 days or older will be considered for third-party collections.",{"name":116,"@type":107,"acceptedAnswer":117},"Who should a patient contact if they need to modify their payment agreement?",{"text":118,"@type":110},"Patients should contact the Office Manager, Brandi Waters, at 912-489-4090 ext. 23.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},359019,1791695317,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962084926284,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Patient Payment Plan  \nI,   , the patient,(Account \\#   ) understand that I am agreeing to the following payment plan between myself and Family Health Care Center. I further understand that I must sign this agreement for it to be valid. All balances must be paid within the timeframe listed below. All unpaid balances 30 days or older will be considered for third party collections.  \n1. In today’s economic times, we understand the hardships you may be going through, and we want to work with you to resolve your balance. Listed below are our payment plan options.  \nPayment Plan  \nMinimum  \nBalance  Payment Amount  \nUnder $100 $25 per month  \n$100- $200 $35 per month  \n$201- $300 $45 per month  \n$300 or above $50 per month  \n2. My current patient account balance is $  as of (date)   .  \nAre claims still pending with insurance? (Circle) Yes No  \nI further understand that if claims are still pending with insurance at this time that I may owe an amount in addition to the amount listed above and furthermore, agree to pay that amount based on this plan as well. Patient’s (or Guarantor’s) Initials    \n3. The monthly payment will be $  and payment will be due on the   of each month.  \n4. I hereby authorize Family Health Care Center to deduct the payment amount monthly on the day indicated above from my debit/credit card account:  \nType of Card (Circle): Mastercard Visa American Express Discover  \nAccount \\#:    \nExpiration Date:   V-Code (3 digit security code):    \nBilling Address Street \\#:   Billing Zip Code:    \n5. Any questions or concerns that I may have had concerning this agreement were answered or discussed with one of the staff members at Family Health Care Center. If this agreement needs to be altered at anytime, I will contact the Office Manager, Brandi Waters, at 912-489-4090 ext. 23 to discuss further options. Patient’s (or Guarantor’s) Initials    \nPatient or Guarantor Printed Name Patient or Guarantor Signature  \nDate Witness: Staff ofFHCC Signature","cbCaio1Qh9S8cCo8","https://ap.wps.com/l/cbCaio1Qh9S8cCo8","pdf",95910,"English","# Patient Payment Plan Agreement\n## Payment Plan Options\n## Account Balance and Insurance Details\n## Monthly Payment Authorization\n## Contact and Agreement Terms","[{\"question\":\"What are the minimum payment requirements based on the account balance?\",\"answer\":\"The plan requires $25/month for balances under $100, $35/month for $100-$200, $45/month for $201-$300, and $50/month for balances $300 or above.\"},{\"question\":\"What happens if an account balance remains unpaid for 30 days or longer?\",\"answer\":\"Unpaid balances 30 days or older will be considered for third-party collections.\"},{\"question\":\"Who should a patient contact if they need to modify their payment agreement?\",\"answer\":\"Patients should contact the Office Manager, Brandi Waters, at 912-489-4090 ext. 23.\"}]","Patient Payment Plan Form | PDF",1790135885]