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Payment Agreement PDF

This document is a payment agreement form for self-pay outpatient services at Boston Medical Center. It provides information about the patient, including their name, address, anticipated date of service, and CPT code for the office visit. The patient can elect to pay the total charges within 30 days for a 40% discount, or with no discount and payment within one year. A minimum 50% down payment is required. Excluded from facility fees are professional services, pharmaceuticals from retail pharmacies, home care services, and durable medical equipment. The patient and BMC representative must sign agreeing to the payment terms.

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Lisa Halajko
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902 views1 page

Payment Agreement PDF

This document is a payment agreement form for self-pay outpatient services at Boston Medical Center. It provides information about the patient, including their name, address, anticipated date of service, and CPT code for the office visit. The patient can elect to pay the total charges within 30 days for a 40% discount, or with no discount and payment within one year. A minimum 50% down payment is required. Excluded from facility fees are professional services, pharmaceuticals from retail pharmacies, home care services, and durable medical equipment. The patient and BMC representative must sign agreeing to the payment terms.

Uploaded by

Lisa Halajko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Exhibit 2

Self Pay Outpatient/Non-SDC Patient


Payment Agreement Form
(Please print when completing this form)

Today’s Date: ________________ Clinic Contact Name: ________________________

Outpatient Visit Location:_____________________________________ Phone: ________


(as entered in SDK location, e.g. H ORTHOPEDIC CLINIC, OR E REHAB MED O/P)

Patient First and Last name: __________________________________MRN: __________

Anticipated Date of Service: ____________ Office Visit/Consultation CPT:_____________

Patient’s Address: _________________________________________________________

Payer’s Name: _________________________________________________________

Payer’s Address: _________________________________________________________

To be completed by Patient Financial Services


 Patient elects to pay total incurred charges within 30 days with 40% discount
50% down payment based on estimated charges with 40% discount =
$ _________ has been paid; this down payment will be applied to the actual
incurred charges.
 Patient elects no discount, total incurred charges will be paid within one year
50% down payment = $________ has been paid, this down payment will be
applied to the actual incurred charges.
Exclusions:
ƒ Boston Medical Center Facility Fees do not include professional services. Professional services are billed
separately.
ƒ Boston Medical Center facility Fees do not include: 1) Pharmaceuticals obtained from retail pharmacies
or from Medical Boston’s hospital based pharmacy (for drugs typically obtained at retail pharmacies, 2)
Home care services, and 3) Durable medical equipment.

Please make payments in U.S. Dollars by check, or credit card, or money order. Please mail or deliver
payment along with this signed letter.
Boston Medical Center
Attention: Patient Financial Services, Customer Service
85 East Concord Street, Ground Floor
Boston, MA 02118

Agreed:
Payer or Patient’s Signature: _________________________ Date:_____________

Agreed:
BMC PFS Signature: ________________________________ Date:_____________

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