Methodist Hospitals | Hospital Billing

Visitors & Patients

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Central Billing Office

Payment Plan Form

Guarantor Name:

Patient Name:

Account 1:

Account 2:

Your Name:

The total balance on these accounts will be divided by six months in order to determine the monthly payment. However, the minimum payment is $25.00 per month, so the plan may actually be less than 6 months. If you want to pay the balance off in less time, please indicate the amount per month you would like to pay.

Comments:

The first payment will be due within 15 days of this arrangement.
Minimum payment $25.00 unless this does not pay the balance off in 6 months.
A statement will be sent to you to confirm payment plan.
Payments must be made in consecutive months in order to remain active.
Accounts in collection do not apply to this arrangement.