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Board of Health P&P Manual,Section I <br /> Policy E,Attachment D <br /> PAYMENT AGREEMENT FORM <br /> In accordance with the policy of the Orange County Health Department, payment is due when <br /> service is provided. However, we realize that there are times when an individual does not have <br /> the total amount of money owed to the clinic, therefore, this written agreement is established as a <br /> method of adopting a payment plan for those patients who have an outstanding balance. <br /> Name Date of Birth <br /> Address <br /> I, , agree to establish a payment plan for my account and <br /> agree to the following: <br /> My account balance is $ <br /> I will pay the amount of$ on my bill. <br /> Monthly Weekly Bi-weekly <br /> I understand that I am responsible for any balance left owing if my insurance company should <br /> not pay the bill in full and that it will be based on my sliding fee scale status. <br /> Signature of Client Date <br /> Signature of OCHD Staff Date <br /> S:\MANAGERS WORKING FILES\BOH\Policies and Procedures\BOH Policy Manual\2015 BOH P&P Manual\I.E. <br /> Attachment D-Prat Agreement.docx <br /> Original:2008 <br /> Revised:8/2013, 11/2014 <br /> 919 245 2400 ) 300 West Tryon Street ) Hillsborough, NC 27278 1 orangecountync.gov <br />