Application for Monthly Payment Arrangements

Please print, complete and sign this form. Return the signed form to Lower Columbia Pathologists by fax (360-425-7219) or mail  to PO Box 3012, Longview, WA 98632.

Date:______________    Account#:_______________    Balance due:$_____________

Name:______________________________________    Phone:___________________

Address:__________________________City________________State_____Zip______

Insurance Information

Company Name:________________________________

Company Address:_______________________________________________________

ID#:______________    Group#:______________    PolicyHolder:___________________

I wish to make monthly payments on my account in the amount of $_____________ per month, beginning on ____________(date). My account will be paid in full within ______months.

Monthly payments must be received every month before the 15th day of each month. If a monthly payment is missed, regular collection procedures will apply and your account may be sent to a collection agency. If your account is over 90 days and payment is not received by the 15th of the month, you may receive a final notice.

Please note that you may not receive your monthly statement before the 15th of each month, however, payment must be received by the 15th.

I understand the above requirement and agree to make the above specified monthly payments to Lower Columbia Pathologists.

Signature___________________________________    Date____________________

Approved by_________________________________    Date____________________

Lower Columbia Pathologists Policy Regarding Credit and Finance Charges

The Federal Truth in Lending Act (Regulation Z) makes it necessary for all firms extending credit to define their credit policy. The Doctor's policy is to extend credit to patients with the understanding that all charges are due and payable within thirty days following the date of billing. The Doctor will extend additional time for payment of accounts to patients who need and/or request it. The maximum credit extended without prior arrangements with our Billing Department is $100.00. If you expect to or do incur charges in excess of $100.00, and wish to extend payment of the account over a period of time, please contact our Billing Department.

Finance percentages and charges, if any, are included on the front of your statement.

Your are responsible for the payment of your account within the limits of our credit policy.

The Doctor's Billing Department shall continue to assist you, in every reasonable way, to complete your insurance claim forms so you may receive reimbursement promptly. Whenever you have questions about your account, please contact our Billing Department.