Palouse Pediatrics

Palouse Pediatrics, Pullman
1205 S.E. Professional Mall Blvd. Suite 104
Pullman, WA 99163 (map)
Phone: 509-332-2605
Fax: 509-334-5754

Palouse Pediatrics, Moscow
1420 S. Blaine St, Suite 5
Moscow, Idaho 83843 (map)
(Located in Eastside Market Place)
Phone: 208-882-2247
Fax: 208-882-2292

Pullman Regional Hospital Clinic Network LLC Payment Plan Agreement Contract

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Fill-out the form below and then print it out. Your information will not be saved or sent.


It is the policy of PRH Clinic Network to gather all outstanding balances on accounts before a patient is seen in the office.  However, we understand that patients may be in situations that require them to make payments on their accounts in order to pay off the balance.  Therefore, we are willing to extend the following payment plan agreement to you.

I ________________________________________, agree to remit payments to PRH Clinic Network LLC under the terms laid out below.

Names and account numbers of patient accounts covered under this agreement:

Name:
Account Number:
Name 2:
Account Number 2:
Current balance of all accounts listed above:
Total months needed to pay the balance off:
Monthly payment plan amount:
Date of first payment:
Amount of first payment:

I understand that failure to make my agreed monthly payment in the mount stated above may result in placement into a collection agency and I agree to pay a collection fee of $25.00.

I understand that should the balance on my account increase due to additional visits being added to my current balance, Pullman Regional Hospital Clinic Network may reassess my account at any time and request that I renew or change my Payment Plan Agreement.

I understand that Payments must be made by the last day of each month in order to keep my account current.

Signature:
Date:
Printed Name:
Relationship to Patient:
Employee Witness:
Date