CHARITABLE SERVICES

PAYMENT BY INSTALLMENT AGREEMENT

PATIENT NAME___________________________________ DOB___________

SS#____________________ DRIVER/STATE ID_______________________

ADDRESS________________________________________APT #_________

CITY________________________STATE____________ZIP _____________

HOME PHONE______________CELL______________EMAIL___________

RESPONSIBLE PARTY____________________________________________

BALANCE OWED CGMH IS $______________________

PAYMENT TYPE:

  1. BY MONEY ORDER MAIL TO CGMY MONTHLY TILL PAID IN FULL AND MONTHLY AMOUNT IS $_________________
  2. BY DIRECT WITHDRAWAL FROM CHECKING ACCOUNT:

BANK NAME___________ ADDRESS______________

ROUTING #___________________ACCT#______________________

AMOUNT TO BE WITHDRAWN MONTHLY $_________________

  1. PAYMENT BY CREDIT CARD AND MONTHLY AMOUNT IS $______. CREDIT CARD NUMBER____________________________

CREDIT CARD EXPIRATION DAY____________________________

SECURITY CODE______________.

PATIENT/RESPONSIBLE PARTY NAME__________________DATE_____

PATIENT/RESPONSIBLE PARTY SIGNATURE_______________________

CGMH OFFICIAL APPROVING AGREEMENT

NAME___________________________ TITLE___________________________

SIGNATURE__________________________________ DATE______________