Online Installment Payment Arrangement

Your application will automatically be emailed to the clinic you select in the drop-down menu.
Clinic Location
Patient Name:*
First Middle Initial Last
Account Number #:
Responsible Party:
*If the patient is under the age of 18.
First Middle Initial Last
Account Balance:
Current Account Balance Amount (Please Enter Amount):
I, the undersigned patient, acknowledge that I have an outstanding account balance with SeMRHI in the amount of $_________which is payable immediately.
Monthly Installment Payment Arrangement Amount (Please Enter Amount):*
In consideration of the agreement of SeMRHI to permit payment of the balance in deferred installments, I agree to pay the Clinic installments of $_____________ per month.
Start Date of Installment Payment Arrangement:*
I agree to make my payments on or before _______________, 20____, and continuing on or before the same day of each following month until the balance is paid in full.
MM slash DD slash YYYY
Patient Acknowledgement:*
I understand and agree that if I fail to pay as agreed above, SeMRHI shall have the right to demand payment of the entire balance, refer the account to a collection agency, and take other measures permitted by law. By signing below, the patient acknowledges this agreement.
Guidelines are as follows:
Payments must be made consecutively each month. If payment is not made, the account will automatically be turned over to collections.
Signature of Responsible Party:*
Signature of Witness (Please leave this area blank. A clinic representative will sign this area.):
Our Mission
To provide access to affordable quality primary and preventive health care to our communities in a patient centered, safe, compassionate environment. Equal Opportunity Provider
Email
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Online Installment Payment Arrangement

Guidelines are as follows:

Our Mission