Templates Patient Payment Agreement Form

Patient Payment Agreement Form

Set up a payment plan with your patients to ensure your practice gets paid on time.

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Money can be a tough topic to discuss with patients. Ease the process by using this patient payment plan agreement form template to define your policies and create a payment plan. Formstack offers a HIPAA compliant data collection solution to help you meet all security standards.

Customizable forms


Brand your patient payment agreement form in minutes. No coding needed. Tweak colors, add logos, and more.

Integrated forms


Easily process insurance, copays, and prescriptions with our HIPAA compliant integrations for Stripe and PayPal.

Powerful forms


Collect and store patient signatures as image files, send automated emails to confirm payment, and much more.

Shareable forms


Add your form to your healthcare website, share it in monthly newsletters, or include it in your org's social profiles.

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