Sample Reminder Letter Page 3

AMPLE

ATIENT

GREEMENT

PATIENT NAME

ACCOUNT #

In consideration of an extension of credit granted to (name)

, as a patient

of (physician) ____________________, agrees to pay the sum of $_________

per month to be applied toward the outstanding balance of $

This amount is due on the _____________ of each month, beginning (date)

___________ and will continue until final payment is made on (date)

________________.

I understand if I fail to make these scheduled payments, my account will be

turned over to an outside collection agency.

SIGNATURE

DATE

PRINT NAME

WITNESS

DATE

RELATIONSHIP TO PATIENT

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Parent category: Life