- Patients who cannot afford to pay their insurance co-pays at once may sign agreement to pay the balance owed over six months.
- The uninsured will only pay 50% of the cost of their care with no questions asked about their income levels and if they are unable to pay this amount at once, they can sign a payment plan to pay over six months.
- Migrant workers, foreign visitors without health insurance, and undocumented individuals and families (people with no immigration status) will be seen without any request to show their social security cards, driver licenses, state/national identification cards, or their immigration status. They will only pay 50% of the cost for their care and will be allowed to sign agreement to pay over six months if they cannot afford 50% at once.
- Patients that cannot speak English will be provided with professional interpreter service to increase their access to care as well.
- No patients will be discharged from our practice for not showing up for appointments except for violence and other unlawful behaviors in our facility.
- Engage in healthcare and prayer missionary work in nations to increase access to care for their citizens.
PAYMENT BY INSTALLMENT AGREEMENT
PATIENT NAME___________________________________ DOB___________
SS#____________________ DRIVER/STATE ID_______________________
BALANCE OWED CGMH IS $______________________
- BY MONEY ORDER MAIL TO CGMY MONTHLY TILL PAID IN FULL AND MONTHLY AMOUNT IS $_________________
- BY DIRECT WITHDRAWAL FROM CHECKING ACCOUNT:
BANK NAME___________ ADDRESS______________
AMOUNT TO BE WITHDRAWN MONTHLY $_________________
- PAYMENT BY CREDIT CARD AND MONTHLY AMOUNT IS $______. CREDIT CARD NUMBER____________________________
CREDIT CARD EXPIRATION DAY____________________________
PATIENT/RESPONSIBLE PARTY NAME__________________DATE_____
PATIENT/RESPONSIBLE PARTY SIGNATURE_______________________
CGMH OFFICIAL APPROVING AGREEMENT